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A  SYNOPSIS  OF 
MEDICAL  TREATMENT 


BY 

GEORGE  CHEEVER  SHATTUCK,  M.D. 

Assistant  Physician  to  the  Massachusetts  General  Hospital 


SECOND  EDITION 
REVISED  AND  ENLARGED 

(Second  Printing) 


BOSTON: 

W.  M.  LEONARD,  Publisher 

1915 


COPYRIGHT 
BY 

W.  M.  LEONARD 

1915 


TO 

WILLIAM  HENRY  SMITH,  M.D. 

TEACHER  IN  MEDICINE 

AND 

FRIEND  TO  MANY 


CONTENTS  AND  INDEX. 


PAGE 

Preface    10 

CHAPTER  I. 
CARDIAC  INSUFFICIENCY. 

Principles  of  Treatment    11 

Methods  of  Treatment : — 

(a)   Rest    11 

( 6 )   Depletion   11 

(c)  Stimulation     15 

( d)  Diet    17 

(e)  Regulation  of  Mode  of  Life 17 

Valvular  Disease: — 

Classification  of  Valvular  Disease 19 

Pathology  and  Diagnosis 19 

Treatment  for:  — 

I.     Congenital  and  Obsolete  Infectious  Valve 

Lesions    21 

II.     Active  Infectious  Lesions 21 

III.     Syphilitic  Valve  Lesions    25 

IV.     Degenerative  VAL^^  Lesions 25 

Hypertension  with  Cardiac  Insl'fficiency 25 

Acute  Pulmonary  EIdema  with  Hypertension 27 

Pulmonary  Edema  without  Hypertension 29 

Circulatory  Disorders  in  the  Infectious  Diseases: — 

Cardiac  Disorders 31 

Vascular  Relaxation,  "Vasomotor  Paresis" 33 

Angina  Pectoris: — 

Classification 35 

Diagnosis    35 

4 


PAGE 

Syphilitic  Angina: — 

Treatmext  IX   Gexeeal    37 

Treatmext  of  Attack    39 

Degenerative  Angina:  Treatmext 39 

Embolic  Axgixa:  Treatmext 41 

Neurotic  Axgix^a  :   Treatmext 41 

CHAPTER  II. 

NEPHRITIS. 

Classificatiox 43 

DlFFEREXTIATIOX    OF   TyPES 45 

Acute  Rexal  Irritatiox:   Treatment 49 

Acute   Nephritis : — 

Prixciples  of  Treatmext 49 

Methods  of  Treatmext:  — 

Sweatixg 49 

purgatiox   51 

Diet    51 

Liquids     53 

nutritiox    53 

Medication    53 

Prophylaxis   53 

Chronic  Nephritis: — 

Prixciples  of  Treatmext 55 

Methods  of  Treatmext   55 

Syphilitic   Nephritis 57 

Arteriosclerotic  Degexeeatiox  :  Treatment 57 

Passive  Congestion:  Treatment 57 

Uremia : — 

Methods  of  Treatment 59 

CHAPTER  HI. 

ACUTE  INFECTIOUS  DISEASES. 

Principles  of  Treatmext 63 

Typhoid  Fever. 

Principles  of  Treatment 65 

Routine  Orders 65 


6 

PAGE 

Methods   of  Treatment:  — 

Prophylaxis 67 

DiLUTiox  AXD  Elimixatiox  OF  Toxixs 69 

Coxsebvatiox  of  Strexgth 69 

Dn:T    69 

Medicatiox    71 

Observatiox    71 

coxvaxescexce 73 

NuRsiXG   73 

Symptomatic  Treatmex^t  :  — 

Fk\er  ax^d  Toxemia 75 

Circulatory  Weakxess    , 79 

DiARRHCEA     79 

coxstipatiox    79 

Distextiox'    81 

vomitixg   81 

Headache    81 

Complications,  Treatmext  of:  — 

Hemorrhage   81 

Pebforattox    83 

Rheumatic   Fever. 

PrIXCIPLES  of  TRFATilEXT 83 

Methods  of  TREAT:\rEXT    83 

Lobar  Pneumcnia. 

Prix'ciples  OF  Treatmext    89 

Methods  of  Treatmext 89 

Stimulation  of  Heart 91 

Delibium  :  Tbeatmext 93 

Broncho-pneumonia 93 

Acute  Inflammation  of  the  Upper  Respiratory  Tract. 

Etiology    93 

Complicatiox*s  axd  Sequell.e 95 

Diagxosis    95 

Prophylaxis 95 

Treatmext  Applicable  ix  Gexeral 95 


7 

PAGE 

Acute  Pharyngitis  :   Treatment 97 

CoRYZA :  Treatment 99 

Acute  Tonsillitis:  Treatment   99 

Acute  Laryngitis  :  Treatment , 101 

Acute  Tracheitis  :    Treatment 101 

Bronchitis,  Acute:  Treatment 103 

Bronchitis,  Chronic:  Treatment 105 

Bronchiectasis:  Treatment 105,  107 

CHAPTER  IV. 
GASTRIC  AND  DUODENAL  ULCER. 

Indications  for  Medical  Treatment 109 

Principles  of  Treatment 109 

Methods    of    Treatment 109 

Diet    Lists 109-113 

Complications,  Treatment  of:  — 

Hemorrhage   113 

Perforation    115 

Pyloric  Obstruction   115 

Persistent  Severe  Symptoms   115 

Acute  Gastritis  and   Gastro-enteritis. 

Diagnosis    119 

Principles  of  Treatment 119 

Methods 119 

Simple  Diarrhoea. 

Diagnosis    123 

Principles  of  Treatment 125 

Methods  of  Treatment 125 

Medication 127 

Constipation. 

Classification 127 

Principles  of  Treatment 129 


8 

i\lETHODS: 

Obstructive  Coxstipatiox   129 

Spasmodic  Coxstipatiox 129 

Atoxic  Coxstipatiox   133 

Vaeio rs    133 


CHAPTER  V. 

Foreword 137 

Abbreviatioxs     139 

SYNOPSIS  OF  DRUGS. 

Important   Drugs: 

1.  Salvaesax  ax^d  Neosalvarsax 139,  143 

2.  Mercttry    147 

3.  Iodide  of  Potash 149 

4.  Diphtheria  Axtitoxix 151 

5.  Moephixe    153 

6.  Digitalis    157 

7.  Nitrogltceeix'  axd  Nitrites 159 

8.  Theobeomixe   161 

9.  ]\Iagxesiu:m  Sulphate  axd  Othee  Puegatives..  163 

10.  QuixiXE 165 

11.  Salicylate   167 

12.  Hexamethylex^amixe    169 

Valuable  Drugs  and  Non-medicinal  Preparations: 

13.  Blaud's  Pill 169 

14.  Tbioxal     171 

15.  Beomide     171 

16.  Phex'acetix' 171 

17.  Do\'er's   Powder 173 

18.  Codeixe   173 

19.  Sodium  Bicarboxate 173 

20.  Bismuth  173 

21.  Calomel    175 

22.  Castor   Oil    175 

23.  Cascara    175 


9 

PAGE 

24.  Vaccine   Vikus 175 

25.  Typhoid  Vaccixe 177 

26.  Tuberculin    177 

27.  Normal  Salt  Solution 177 

28.  Alcoholic  Be\'erages    179 

29.  "Russian  Oil" 179 

30.  Agar-Agar    181 

Drugs  Valuable  for  Occasional  Use: 

List  of  : , 181 

Drugs  in  Common  Use: 

List  of : 183 

Tables  of  Weights  and  Measures 185 


PEEFACE. 


This  work  represents  an  attempt  to  offer  clearly  and 
concisely  sound  principles  of  treatment  based  on  known 
pathology.  The  methods  described  are  selected  from  those 
that  have  been  tried  at  the  Massachusetts  General  Hospital 
or  in  private  practice.  Most  of  them  have  been  taught 
by  Prof.  F.  C.  Shattuck,  Dr.  William  H.  Smith  or  others  on 
the  staff  of  the  Hospital  or  of  the  Harvard  Medical  School. 
It  is  not  to  be  supposed  that  any  of  these  men  subscribe 
fully  to  everything  here  set  forth  or  that  further  advance 
will  not  require  revision. 

The  writer  wishes  here  to  express  his  deep  appreciation 
of  the  debt  which  he  owes  to  his  teachers  in  medicine,  of 
their  kindliness  to  their  pupils  and  of  their  humanity  to 
their  patients. 

Brevity  being  essential  to  the  writer's  purpose,  this 
synopsis  is  necessarily  incomplete.  The  book  was  prepared 
primarily  for  use  in  the  Harvard  Medical  School. 


PREFACE   TO   SECOND   EDITION. 


In  this  edition,  as  in  the  first,  completeness  has  been 
sacrificed  for  brevity,  but  new  material  has  been  added  and 
many  changes  have  been  made. 

More  reliance  than  before  has  been  placed  on  personal 
experience,  but  the  information  about  salvarsan  was  de- 
rived, chiefly,  from  recent  literature. 

It  is  a  pleasure  to  acknowledge  the  assistance  and  help- 
ful criticism  of  friends  and,  notably,  that  of  Mr.  Godsoe, 
Pharmacist  of  the  Massachusetts  General  Hospital. 

G.   C.   S. 
Note. 

In  this  printing  errors  have  been  corrected  and  minor 
changes  and  additions  have  been  made. 

The  names  of  unofficial  drugs  have  been  spelled  as  in  the 
Nineteenth  Edition  of  the  United  States  Dispensatory. 

10 


CHAPTER  I. 


CARDIAC  INSUFFICIENCY. 

GENERAL  PRINCIPLES  OF  TREATMENT. 

A.  Rest. 

B.  Depletion. 

C.  Stimulation. 

D.  Suitable  Diet. 

E.  Regulation  of  Mode  of  Life. 

The  principles  are  much  the  same  whatever  the  under- 
lying cause.  Treatment  must,  however,  he  regulated  to 
suit  the  severity  of  symptoms,  to  meet  individual  needs, 
c-nd  for  varieties  of  disease. 

An  exact  diagnosis  may  be  difficult  in  the  presence  of 
severe  insufficiency  and  may  not  be  necessary  at  first,  but 
accuracy  in  diagnosis  is  very  important  for  prognosis  and 
for  planning  treatment  for  the  future. 

METHODS    OF   TREATMENT. 

A.     Rest. 

1.  Semirecumbent  position  in  bed  or  chair. 

2.  Minimum  exertion. 

3.  Relieve  discomfort  and  secure  sleep.     If  there  is  much 

discomfort  morphine  subcutaneously  is  indicated. 

B.     Depletion. 

1.  Purgation.     Obtain  watery  catharsis  more  or  less  pro- 
fuse according  to  amount  of  edema. 
When  edema  is  absent  or  slight  avoid  excessive  purgation 
lest  exhaustion  result. 
Magnesium  sulphate  (p.  163)  is  useful  as  a  purgative. 

11, 


13 


2.  Limitation  of  Liquids.  Total  liquids,  including  liquid 
foods,  should  not  exceed  three  pints  in  twenty-four  hours. 
One  pint  in  twenty-four  hours  is  near  the  minimum.  The 
patient  should  not  be  allowed  to  suffer  from  thirst. 
It  may  be  relieved  by  sucking  cracked  ice  or  by  gar- 
gling. 

3.  Diuresis  should  follow  the  use  of  digitalis.  In  mild 
cases  of  insufficiency,  rest,  purgation  and  limitation  of 
liquids  with  or  without  digitalis  may  suffice. 

When  edema  is  persistent  or  extreme,  diuretics  should  be 
prescribed.  Theobromine  (p.  161)  or  its  substitutes  may  be 
expected  to  act  well  provided  the  kidneys  are  not  severely 
damaged.  Calomel  should  not  be  given  if  the  patient 
has  nephritis  because  salivation  may  result.  Apocynum, 
theocine  or  theophylline  may  act  better  than  theobromine 
in  some  cases. 

4.  Venesection.  Indicated  occasionally  when  there  is 
engorgement  of  the  right  ventricle  with  marked  evidence 
of  venous  stasis;  e.g.  dyspnoea,  cyanosis,  pulmonarj^ 
edema  and  engorgement  of  neck-veins  and  liver. 

A  pint  of  blood  or  even  more  may  be  withdrawn.  Vene- 
section is  contraindicated  by  emaciation  or  by  marked 
weakness  or  anemia.  Blood  is  generally  withdrawn  by 
incising  a  vein  on  the  inner  side  of  the  elbow.  A  tourni- 
quet may  be  put  around  the  arm  to  render  the  veins  prom- 
inent. The  incision  should  be  made  in  the  long  axis  of  the 
vein  with  the  point  of  a  sharp  knife.  The  bleeding  can  be 
stopped  with  a  pad  and  bandage.  Suturing  the  vein  is  un- 
necessary. 

5.  Leecliing,  Useful  as  a  substitute  for  venesection 
when  the  latter  would  be  undesirable  or  when  symptoms 
are  less  severe.  Leeching  will  generally  relieve  painful 
engorgement  of  the  liver. 

Apply  a  dozen  leeches  over  the  right  hypochondrium 
and  allow  them  to  remain  until  they  drop  off.  The  abdo- 
men should  then  be  covered  with  a  large,  moist,  absorbent 
dressing  to  favor  oozing  from  the  bites.  A  drop  of  milk 
placed  on  the  skin  encourages  the  leech  to  bite.  Salt 
causes  him  to  let  go. 


15 


6.  Tapping.  Necessary  when  fluid  in  the  chest  or  ab- 
dominal cavity  seriously  embarrasses  the  heart  or  respira- 
tion. 

C.     Stimulation. 

Digitalis  (p.  157)  is  the  best  cardiac  stimulant  (other 
drugs  may  be  preferred  occasionally).  A  good  tincture  of 
digitalis  ordinarily  acts  well.  If  after  pushing  digitalis  no 
effects  are  apparent  the  preparation  is  probably  bad. 
When  given  by  mouth  in  sufficient  dosage  its  action  should 
be  apparent  in  from  twenty-four  to  forty-eight  hours. 
When  quicker  results  are  needed  an  initial  dose  of  30  min. 
(or  2  c.c.)   may  be  injected  into  the  gluteal  muscle. 

When  prompt  effects  are  desirable  digipuratum  (p.  159) 
can  be  used.  When  given  by  mouth  it  should  act  in  from 
twelve  to  twenty-four  hours.  Digipuratum-solution  in- 
jected intramuscularly  may  show  effects  in  from  |  to  1 
hour.  It  acts  more  quickly  w^hen  used  intravenously.  For 
very  urgent  insufficiency  strophanthin  may  be  used  in- 
travenously.    It  is  dangerous   (p.  159). 

Caffeine  sodio-salicylate  is  believed  to  promote  diuresis 
when  used  in  conjunction  with  digitalis.  For  this  purpose 
the  caffeine  should  be  used  subcut.  in  repeated  doses  of 
from  1  to  3  grs.   (or  0.06  to  0.2  gm.). 

Black  coffee  or  caffeine  citrate  may  be  tried  by  mouth. 
Caffeine  may  cause  restlessness  or  insomnia. 

Slight  exacerbations  of  dyspnoea  or  distress  can  often  be 
relieved  by  a  quickly  diffusible  stimulant,  e.g.: 

By  mouth: 

(a)   Spiritus   ammonise   aromaticus:    1   drach.    (or   4 
c.c). 
(Z))   Spiritus  setheris  compositus,  "  Hoffmann's  ano- 
dyne: "  1  drach.  (or  4  c.c). 

(c)  Whiskey  or  brandy:  from  ^  to  1  oz.   (or  15  to 

30  c.c). 

Subcutaneously : 

(d)  Whiskey,  brandy  or  ether:  1  drach.  (or  4  c.c). 

Inject  intramuscularly. 


17 


(e)  Camphor  in  oil:  *  3  grs.  (or  0.2  gm.).  Inject 
intramuscularly. 

if)  Cocaine  liydrocliloride:  from  J  to  ^  gr.  (or 
0.008  to  0.016  gm.).  It  is  said  to  be  dan- 
gerous but  may  act  very  well. 

Insufficiency  with  much  pain  requires  morphine  (p.  153). 
It  seems  to  act  under  these  circumstances  as  an  efficient 
cardiac  stimulant.  It  brings  also  physical  comfort  and  psy- 
chic relief  which  favor  recuperation.  The  morphine  should 
be  used  subcut.  under  these  circumstances  to  ensure  prompt 
effect. 

D.     Diet. 

Spare  the  patient  unnecessary  effort,  particularly  if  there 
is  much  dyspnoea,  by  ordering  food  which  is  easy  to  swallow 
and  which  requires  no  chewing. 

By  frequent  small  feedings  and  by  avoiding  gas-producing 
foods  seek  to  prevent  cardiac  embarrassment  from  disten- 
tion. 

Emaciated  patients  should  take  as  much  concentrated 
nourishment  as  is  practicable  in  order  to  strengthen  the 
heart  muscle  by  improved  nutrition. 

Fat  or  plethoric  individuals  may  benefit  by  relative  star- 
vation. 

E.     Regulation   of   Mode   of   Life. 

To  prevent  relapse  during  and  after  convalescence,  the 
mode  of  life  of  the  patient  must  be  wisely  regulated;  and 
intelligent  cooperation  between  patient  and  physician  is  es- 
sential to  this  end.  It  is  generally  necessary  to  tell  the 
patient  something  about  his  condition  and  to  warn  him  to 
avoid  activities  which  induce  much  fatigue  and  exertions 
which  cause  much  dyspnoea. 

Judgment  and  caution  must  be  exercised  in  dealing  with 
an  apprehensive  patient  lest  danger  be  exaggerated  in  his 
mind,  and  harm  result.  After  a  sufficient  period  of  com- 
plete rest  the  patient  should  be  encouraged  to  take  regular 


*  Should  be  specially  prepared  for  subcut.  use. 


19 


exercise    within    the     limits     of    tolerance    in     order     to 
strengthen  the  heart  by  promoting  hypertrophy. 

Exercise   and   work   should   be   resumed   very   gradually 
under  close  supervision. 

CLASSIFICATION   OF  VALVULAR  DISEASE. 

rMost     commonly     discovered     in 
M      early  childhood 


1.  Congenital 

2.  Infectious 

3.  Syphilitic 

4.  Degenerative 


rMost     commonly     discovered     in 
I     youth. 
Most     commonly     discovered     in 

middle  life. 
rMost  commonly  discovered  in  old 
]^    age. 


NOTES    ON    PATHOLOGY    AND    DIAGNOSIS. 

1.  Congenital  lesions.  Pulmonic  stenosis  is  the  most 
common.  It  is  seldom  mistaken  for  other  types  of  lesion 
but  may  easily  be  confused  with  anomalies  which  have  sim- 
ilar signs  and  which  are  often  combined  with  it. 

2.  Infectious  lesions: 

(a)  Active  stage.     Inflammation  of  valves  due  to  pres- 
ence of  bacteria  on  the  valve. 

(b)  Obsolete  stage.     Valves  deformed  and  scarred  as  a 
result  of  inflammation. 

(c)  Recurrent    stage.     Reinfection    with    inflammation 
at  site  of  old  lesion. 

Lesions  are  found  commonly  at  the  mitral  valve  or  at  the 
aortic  and  mitral  valves,  seldom  at  the  aortic  valve  alone. 
Occasionally  the  mitral,  aortic  and  tricuspid  valves  are  all 
diseased.     Stenosis  develops  frequently. 

Obsolete  lesions  if  well  compensated  may  give  no  symp- 
toms. They  first  attract  attention  by  diminished  cardiac 
efficiency  or  by  failure  of  compensation. 

In  the  active  or  recurrent  stage  the  symptoms  are  those 
of  general  infection  with  or  without  failure  of  compensa- 
tion. 

3.  Syphilitic  lesions.  The  lesion  generally  begins  in  the 
ascending   aorta    and    extends    subsequently    to    the    aortic 


21 


valve.  The  earliest  signs  may  be  slight  dilatation  of  the 
arch  and  the  murmur  of  aortic  roughening.  Later,  that  of 
aortic  regurgitation  may  appear  and,  finally,  relative  mitral 
regurgitation  may  develop. 

A  lesion  of  the  aortic  valve  only,  in  a  young  adult,  sug- 
gests syphilis  as  its  cause.  Aneurism  or  coronary  endar- 
teritis may  coexist  as  part  of  the  same  process. 

Evidence  of  an  old  syphilis  supports  the  diagnosis. 

4.  Degenerative  lesions.  As  in  syphilis,  the  signs  point 
to  a  lesion  at  the  aortic  valve  but  evidence  of  syphilis  is 
lacking.  The  background  is  one  of  senility  and  general 
arteriosclerosis  to  which  sclerosis  of  the  aorta  and  of  the 
aortic  valve  is  incidental.  There  may  be  dilatation  of  the 
arch  and  evidence  of  myocardial  degeneration,  perhaps  also 
angina  pectoris. 

Islote. —  All  the  types  of  lesion  enumerated  above  may  be 
followed  in  time  by  cardiac  insufficiency. 

TREATMENT   FOR  TYPES   OF   VALVULAR 
DISEASE. 

I.  Congenital     and     Obsolete     Infectious     Lesions     of 
Valves. 
Treat  according  to  the  general  principles  given  above. 
They  must  be  modified  for  the  individual  with  re- 
gard  to    severity,    duration,    nature    and   cause    of 
symptoms. 

II.  Active  Infectious  Lesions  of  Valves. 
A.  Principles  of  Treatment.     As  for   acute   infections  in 
general  (p.  23)   and  for  cardiac  insufficiency  if  present. 

1.  Rest  in  bed. 

2.  Minimum  exertion. 

3.  Dilution  of  toxins. 

4.  Elimination   of  toxins. 

5.  Maintenance  of  nutrition. 

6.  Stimulation  p.r.n. 

Note. —  The  infection  may  be  acute,  subacute  or  recur- 
rent. The  chief  dangers  are  from  toxemia,  exhaustion, 
cardiac  dilatation  or  embolism. 


23 


A  history  of  recent  preexisting  rheumatic  fever,  chorea 
or  tonsillitis  strengthens  a  diagnosis  of  active  endocarditis. 

B.  Methods,  (a)  Good  nursing  is  very  important.  The 
nurse  should  promote  comfort  by  attention  to  details,  should 
feed  the  patient  and,  whenever  possible,  spare  him  exer- 
tion or  annoyance. 

(&)  To  dilute  toxins  and  to  favor  elimination  order 
abundance  of  liquids.  Have  intake  and  output  recorded. 
If  cardiac  dilatation  threatens  or  if  there  is  edema  liquids 
must  be  restricted. 

(c)  Feedings  should  be  frequent,  the  food  nutritious,  and 
the  amount  regulated  b/  digestive  power.  Liquids  and  soft 
solids  are  preferable  in  severe  cases  because  easy  to  swal- 
low. 

(d)  Stimulants  are  to  be  avoided  unless  clearly  neces- 
sary because  embolism  is  to  be  feared  and  stimulation 
might  favor  it. 

(e)  Sodium  salicylate  (p.  161)  or  aspirin  in  large  doses 
may  be  tried.  Small  or  moderate  doses  of  salicylate  are 
not  likely  to  do  good  in  endocarditis. 

(f)  Tachycardia  may  sometimes  be  reduced  by  an  ice- 
bag  placed  over  the  prsecordia. 

C.  Convalescence.  To  minimize  danger  of  relapse  keep 
the  patient  in  bed  and  as  quiet  as  possible  for  weeks  or 
months  after  the  pulse  and  temperature  have  returned  to 
normal.  Permanent  damage  nearly  always  remains.  The 
degree  of  possible  improvement  depends  on  the  location 
and  extent  of  the  lesions  and  on  the  recuperative  power 
of  the  patient.  Therefore,  guard  against  strain,  and  treat 
malnutrition  or  anemia,  if  present,  to  promote  hypertrophy 
of  the  heart. 

D.  Prophylaxis,  (a)  Search  for  and  eliminate  all  foci 
of  infection. 

(&)  Diseased  tonsils,  as  a  rule,  should  be  removed  at  the 
first  suitable  opportunity.  It  is  dangerous  to  remove  them 
when  acutely  inflamed. 

(c)  Warn  the  patient  against  exposure  and  advise  him 
to  attend  promptly  to  ailments,  even  if  slight,  and  to  avoid 
mental  strain,  and  physical  exertion  which  produces  dysp- 
noea or  fatigue. 

* 


25 


III.  Syphilitic  Lesions  of  Valves  require  antisyphilitic 
medication  as  well  as  general  measures  for  cardiac  insuf- 
ficiency. 

Little  improvement  can  be  expected,  however,  unless  the 
diagnosis  be  made  before  extensive  and  irreparable  damage 
has  occurred. 

IV.  Degenerative  Lesions  of  Valves  may  be  treated  on 
general  principles  with  certain  modifications  as  follows: 

(a)  When  blood-pressure  is  high,  nitrites  may  be  of 
value  to  lighten  the  work  of  the  heart  by  lowering  pressure 
temporarily. 

(&)  Thin  patients  require  the  maximum  nutrition  to 
strengthen  the  heart.  They  should  undergo  little  or  no 
purgation  unless  edema  is  considerable. 

(c)  Regulation  of  life  is  of  the  utmost  importance  dur- 
ing and  after  convalescence.  The  patients'  cooperation 
must  be  secured. 

(d)  Many  of  these  patients  should  take  digitalis  ahd 
salts  more  or  less  frequently  for  long  periods  or  for  the  rest 
of  their  lives.  The  best  dosage  for  the  individual  can  be 
determined  only  by  trial.  Several  small  doses  per  week 
taken  at  regular  intervals  may  be  sufficient.  Warn  the  pa- 
tient not  to  be  without  his  medicine  or  to  give  it  up  on 
his  own  responsibility.  The  heart  muscle  may,  perhaps, 
be  so  changed  that  it  cannot  respond  to  any  form  of  treat- 
ment. 

HYPERTENSION  WITH  CARDIAC 
INSUFFICIENCY. 
Etiology  and  Symptoms.  Hypertension  is  commonest  in 
chronic  nephritis  and  is  seen  also  in  arteriosclerosis.  The 
hypertension  and  left  ventricular  hypertrophy  develop 
gradually.  Symptoms  of  insufficiency  often  increase  so 
gradually  as  to  be  disregarded  by  the  patient  for  months. 
The  condition  of  the  patient  is  generally  more  critical  than 
the  signs  would  seem  to  indicate.  Acute  pulmonary  edema 
is  common  in  these  cases.  Many  of  them  show  signs  of 
toxemia  attributable  to  deficient  renal  elimination. 

Treatment.     1.  Methods  for  cardiac  insufficiency   (p.  11). 
2.  Reduce   the   work   of  the   heart  by   lowering  blood- 


27 


pressure  temporarily  unless  the  urinary  output 
falls  in  consequence. 

(a)  Vaso-dilators,  e.g.,  nitroglycerin  (p.  159),  lower 
blood-pressure  temporarily  and  often  promote 
diuresis  also. 

(&)  Purgation,  diuresis,  venesection  and  measures 
tending  to  relieve  toxemia  or  to  improve  the  cir- 
culation seem  to  favor  if  not  to  cause  reduction 
of  pressure  in  hypertension. 

(c)  Starvation  for  a  day  or  marked  restriction  of  food 
for  several  days  may  benefit  plethoric  individu- 
als. It  is  one  of  the  surest  means  of  lowering 
pressure.  Emaciation  must  be  avoided  because 
it  increases  cardiac  weakness. 

{d)  Relief  from  psychic  strain,  e.g.,  business  cares, 
may  be  followed  by  a  fall  in  pressure. 

3.  When  toxemia  is  present  reduce  it  by: 
(a)   Purgation  or  diuresis. 

(&)   Restriction  of  food,  and  of  proteid  in  particular, 
(c)   Hot-air  baths   or   hot   soaks   if   cardiac   symptoms 
permit. 

4.  If  toxemic  symptoms   persist  after   improvement   in 

the  circulation  they  are  probably  uremic  in  or- 
igin and  should  be  treated  accordingly  (p,  57). 

ACUTE  PULMONARY  EDEMA  IN 
HYPERTENSION. 

Notes. —  Occurs  commonly  and  characteristically  in  hyper- 
tension. The  attack  generally  follows  exertion  and  may 
not  have  been  preceded  by  marked  symptoms  of  cardiac 
insufficiency. 

The  onset  is  sudden  and  alarming. 

The  symptoms  are  severe  dyspncea,  cyanosis,  wheezing, 
cough,  and  pinkish,  frothy  expectoration.  There  may  be 
prsecordial  pain. 

Treatment.  Mild  attacks  may  pass  off  after  a  little  rest. 
Severe  attacks  require  energetic  and  prompt  treatment  as 
follows: 

1.  Prop  the  patient  up  so  he  can  sit  upright  without 
effort. 


By  mouth: 


29 

2.  Give  morphine  sulphate,  gr.  i    (or  0.016  gm.)    atro- 

pine sulphate,  gr.  ^i^  to  ^\  (or  0.00065  to  0.001 
gm.)  and  nitroglj^cerin,  gr.  yig  to  Jg  (or  0.00065 
to  0.001  gm.)   subcutaneously  at  once. 

3.  Unless  improvement  begins  promptly,  the  nitroglyc- 

erin should  be  repeated,  and  venesection  may  be 
performed. 

4.  The  following  drugs  may  be  of  service: 

By  inhalation:  Amyl  nitrite:    5  m.    (or  0.3   c.c). 

'Spiritus     ammoniae     aromaticus:      1 

drach.    (or   4   c.c). 

Spiritus      setheris      compositus:  *      1 

drach.    (or  4  c.c). 

Whisky  or  brandy:   from  4  drach.  to 

^     1  oz.    (or  15  to  30  c.c). 

r  Cocaine     hydrochloride:     i     gr.     (or 
Subcutaneously:  |     ^^^^  ^^^  .    ^^.^  ^^  ^^  dangerous. 

Intravenously:  Strophanthin:   dangerous   (p.  159). 

5.  Do  not  attempt  to  transport  the  patient  until  imme- 

diate danger  has  passed. 

6.  Rest  in  bed  is  advisable  for  a  few  days  to  allow  the 

heart  to  recover  itself. 

7.  Digitalis,   purgation,  etc.,  may  be  needed. 

8.  Subsequent  regulation  of  life   is   essential  to   avoid 

recurrence. 

Pulmonary  Edema  without  Hypertension.  Pulmonary 
edema  may  appear  in  cardiac  insufficiency  from  any  cause. 
It  is  common  in  mitral  stenosis,  but  seldom  acute  enough 
to  require  special  treatment.  When  severe  it  should  be 
treated  as  in  hypertension,  except,  that  the  blood-pressure 
being  normal  or  low,  nitrites  are  of  doubtful  value  and  may 
perhaps  do  harm. 

Pulmonary  edema  occurs  also  in  infectious  diseases.  In 
pneumonia  it  may  be  very  acute,  but  is  not  necessarily  of 
cardiac  origin.  For  treatment  see  p.  31;  also  "Typhoid 
Fever,"  pp.  71,  73,  and  "  Pneumonia,"  p.  91. 


*  "  Hoffmann's   anodyne." 


31 


CIRCULATORY    DISORDERS    IN    THE    INFEC- 
TIOUS  DISEASES. 

Note. —  Common  in  acute  infections,  particularly  in  pneu- 
monia and  in  septic  states.  The  circulatory  disturbances 
may  be  attributed  to  one  of  the  following  causes  or  to  a 
combination  of  them. 

A.     CAUSES. 

1.  Faulty  innervation  of  the  heart  due  to  toxemia. 

2.  Cloudy  swelling  of  myocardium  due  to  toxemia. 

3.  Ill-nourished  myocardium  secondary  to  emaciation  or 

anemia. 

4.  Infection  of  the  valves,   myocardium  or  pericardium. 

5.  Lesions    obstructing    the    pulmonary    circulation,    e.g., 

embolism   of  the   pulmonary   artery   or   of   its   large 
branches. 

6.  Vasomotor  relaxation  or  paresis  due  to  toxemia. 

B.     TREATMENT  IN  GENERAL. 

1.  Dilute,  eliminate  or  neutralize  toxins. 

2.  Minimize  exertion. 

3.  Prevent  abdominal  distension. 

4.  Strive  to  maintain  nutrition. 

5.  Emaciated  patients,  capable  of  taking  little  food, 
sometimes  do  well  on  large  doses  of  alcohol  which  seem  to 
act  for  them  as  a  food  and  indirectly  as  a  stimulant. 

6.  Cardiac  stimulants  must  often  be  tried  empirically 
from  lack  of  a  precise  diagnosis  or  as  a  last  hope.  They 
often  fail  to  do  good. 

C.     TREATMENT  IN  PARTICULAR. 

I.  Cardiac   Disorders. 

1.  Faulty  Innervation.  Alcohol,  digitalis,  strychnine  or 
ice-bag,  etc.,  may  be  tried  but  are  not  likely  to  avail  much. 

2.  Cloudy  Swelling.  Digitalis,  caffeine  or  camphor  may 
be  tried. 

3.  Ill-nourished  Myocardium  demands  improved  nutrition 
of  the  patient.     Alcohol  and  stimulants  may  perhaps  help. 


I 


33 


4.  Cardiac  Infection.  Treat  as  for  active  infectious  endo- 
carditis, p.  21, 

5.  Obstruction  in  the  Lung.  As  a  rule  nothing  can  be 
done. 

6.  Pulmonary  Edema  occasionally  yields  promptly  to 
atropine,  used  subcutaneously.  Cardiac  stimulants  or 
strophanthin  (dangerous,  p.  159)  may  be  tried.  Venesec- 
tion may  do  good  if  the  edema  be  attributable  directly  to 
cardiac  dilatation. 

II.  Vascular    Relaxation:    "Vasomotor   Paresis." 

Notes. —  The  relaxation  is  believed  to  be  the  result  of 
vasomotor  paresis  produced  by  the  action  of  toxins  on  the 
vasomotor  center.  It  occurs  occasionally  in  severe  infec- 
tions, particularly  in  typhoid  and  in  pneumonia.  The  con- 
dition is  analogous  to  surgical  shock  although  its  cause  is 
not  the  same. 

The  onset  may  be  gradual  or  rapid.  It  can  be  observed, 
by  watching  the  development,  that  the  pulse  becomes  weak 
while  the  heart-sounds  are  still  of  good  quality.  Later,  as 
a  result  of  low  peripheral  pressure  and  meager  return  of 
blood  to  the  heart,  the  heart's  action  becomes  more  and 
more  rapid,  the  sounds  fainter  and  perhaps  irregular. 
Finally,  the  extremities  become  cold,  the  face  pale  and  the 
pulse  imperceptible. 

Principles  of  Treatment.  Promote  return  of  blood  to  the 
heart  by: 

(a)   Filling  the  vessels,  or  by 
(&)   Constriction  of  vessels. 

Methods:  1.  Salt  solution  used  by  hypodermoclysis  is 
rapidly  absorbed  and  generally  acts  well  in  from  five  to 
fifteen  minutes.  It  may  save  life  even  when  the  patient's 
condition  is  very  bad.  A  pint,  heated  to  blood-temperature, 
should  be  used  at  a  time.  It  may  be  repeated  in  an  hour 
or  later  if  needed.  The  administration  of  frequent  doses 
of  salt  solution  in  this  way  may  lead  to  cardiac  dilatation 
unless  excretion  be  rapid. 

Salt  solution  may  be  given  intravenously  in  very  critical 
conditions. 


35 

When  the  need  for  salt  solution  can  be  anticipated  the 
means  of  administering  it  should  be  kept  in  readiness. 

2.  Direct  transfusion  of  blood  might  be  tried  if  it  could 
be  done  without  delay. 

3.  Adrenalin  chloride  is  a  very  powerful  vaso-constrictor 
but  very  transient  in  its  effect.  It  is  difficult  to  get  satis- 
factory results  with  it. 

Pituitrin  has  an  effect  on  blood-pressure  like  adrenalin, 
but  milder  and  less  transient.     It  may  be  tried  safely. 

Caffeine  sodio-salicylate,  3  gr.  (or  0.2  gm.),  may  be  tried 
subcutaneously,  but  is  not  very  effective  as  a  vaso-con- 
strictor. 

ANGINA  PECTORIS. 

Definition.  Pain  or  distress  attributable  to  spasm,  or  to 
occlusion,  of  a  coronary  artery. 

Spasm  is  generally  associated  with  syphilitic  or  degen- 
erative change  in  the  vessel-wall,  but  lesions  may  be  con- 
fined to  other  parts  of  the  heart  or  to  the  aorta,  and 
"  neurotic  angina,"  in  which  there  is  no  known  lesion,  is 
rather  common.     Occlusion  may  be  thrombotic  or  embolic. 

Angina  may  be  indicative  of  threatened  exhaustion  or  of 
deficient  blood-supply  to  the  myocardium. 

Etiological  Classification  of  Angina  Pectoris. 

1.  Syphilitic:  common  in  men  of  early  middle  age. 

2.  Degenerative  or  arteriosclerotic:    common  in  old  men. 

3.  Embolic:    seen   in  endocarditis  or  intracardiac  throm- 

bosis. 

4.  Neurotic:  common  in  young  women, 

DIAGNOSIS. 

An  accurate  history  of  the  mode  of  onset,  duration  and 
radiation  of  the  pain  and  the  discovery  of  an  adequate 
background  for  the  disease  is  of  the  greatest  importance. 
Pain  on  exertion  suggests  angina.  Angina  in  a  young  or 
middle-aged  man  suggests  syphilis. 

A  complete  physical  examination  may  show  nothing  im- 


37 

portant.     Angina    in    a    young    woman    suggests    psychic 
trauma. 

Painless  angina,   otherwise   typical,   is   seen   rarely. 

I.  SYPHILITIC    ANGINA. 

Pathology.  Syphilitic  changes  in  the  aorta,  aortic  valves 
or  coronary  arteries,  diminishing  their  circulation  are  gen- 
erally demonstrable. 

Etiology.  A  late  manifestation  of  syphilis;  commonest 
in  middle  life. 

Prognosis.     The  prognosis  is  very  uncertain. 

A.     Treatment  in  General. 

1.  Antisyphilitic  measures.* 

2.  Regulation  of  life  to  reduce  demands  on  the  heart  to 
what  it  can  meet  is  of  the  utmost  importance. 

(a)   Avoid  anything  known  to  bring  on  angina  in 

the   individual,   e.g.,   exercise   after  meals. 
(&)   Avoid  pJiysical  and  mental  strain. 

(c)  Avoid   distention   of  the   stomach  and  bowels. 

(d)  Food  and  liquids  should  be  taken  in  modera- 

tion. 

(e)  Tobacco   and    alcohol    in   great   moderation    if 

at  all. 
if)   Bowels  should  be  kept  free. 

3.  Cardiac  insufficiency,  if  present,  requires  appropriate 
treatment  on  general  principles. 

4.  Small  doses  of  digitalis  often  help  to  reduce  the  num- 
ber of  attacks  even  when  the  usual  signs  of  cardiac  in- 
sufficiency are  absent.  Theobromine  sodio-salicylate,  grs. 
5  t.i.d.,  or  barium  chloride,  grs.  %o  t.i.d.,  may  be  tried  for 
the  same  purpose. 

5.  At  the  first  sign  of  an  attack  the  patient  should  take 
nitroglycerin  (p.  159)  or  amyl  nitrite,  repeat  it  in  a  few 
minutes  if  not  relieved  and  remain  quiet  for  a  time  after 
the  attack  has  passed.  An  expected  attack  can  sometimes 
be    prevented    by    timely    use    of    nitroglycerin.     The    drug 


*  It   is    doubtful   whetlier    Salvarsan    should   be   used   in   the   presence 
of  severe  cardiac  disease. 


S9 


must  be  always  accessible  without  effort.  Nitroglycerin 
should  be  chewed  and  absorbed  in  the  mouth  and  amyl 
nitrite  taken  by  inhaling  it  from  a  handkerchief.  It  is 
important  to  provide  pearls  which  break  easily  but  not 
spontaneously  if  amyl  nitrite  is  to  be  used. 

B.     Treatment  of  Anginal  Attacks. 

If  called  to  treat  an  attack  of  angina  use  nitroglycerin 
subcutaneously  or  amyl  nitrite  or  both  immediately.  Repeat 
the  dose  in  a  few  minutes  if  the  patient  is  not  relieved. 
If  nitroglycerin  gives  no  effect  in  repeated  doses  amyl 
nitrite  may  perhaps  relieve.  If  the  pain  is  unusually  se- 
vere and  obstinate  morphine  may  be  injected. 

Do  not  attempt  to  transport  the  patient  and  do  not  allow 
him  to  make  the  slightest  exertion  for  a  time  after  the 
symptoms  have  passed.  Rest  in  bed  is  advisable  after  a 
severe  attack. 

That  which  is  known  to  bring  on  an  attack  must  be 
avoided. 

II.  DEGENERATIVE  ANGINA. 

Pathology.  Coronary  sclerosis  and  chronic  myocardial 
degeneration,  with  or  without  fibrous  myocarditis,  will 
often  be  demonstrable  as  part  of  a  widespread  arteri- 
osclerosis. 

Prognosis.  Years  of  life  may  be  possible  but  sudden 
death  may  occur  at  any  time. 

Treatment.     1.  Regulate  life  to  avoid  strain. 

2.  When  there  is  any  evidence  of  cardiac  insufficiency  it 
may  be  well  for  the  patient  to  use  digitalis  and  salts  for 
long  periods.  The  required  dose  for  the  individual  should 
be  carefully  determined  by  trial. 

3.  Digitalis,  theobromine  or  potassium  iodide  in  small 
doses  may  limit  the  number  of  attacks. 

4.  If  an  old  syphilis  be  suspected  give  potassium  iodide 
and  protiodide  of  mercury  in  moderate  doses. 

5.  For  attacks  the  treatment  is  the  same  as  in  syphilitic 
angina. 


41 


III.  EMBOLIC  ANGINA. 

Vaso-dilators  are  likely  to  give  little  relief.  Morphine  is 
usually  required  in  large  doses.  (Death  may  come  sud- 
denly at  onset  of  symptoms.) 

IV.  NEUROTIC  ANGINA. 

Pathology.     No  characteristic  changes   recognized. 

Etiology.  Commonly  due  to  excess  in  tea,  coffee,  or  to- 
bacco, to  fear  or  emotional  shock  and  often  associated  with 
debility.  It  is  seen,  almost  exclusively,  in  neurotic  young 
women. 

Prognosis.  Death  is  not  to  be  expected  and  the  chance 
of  complete  cure  is  excellent. 

Treatment.     1.  Remove  the  cause  when  possible. 
2.  General  hygienic  measures. 

By  these  means  recurrence  can  be  prevented. 

The  attack  is  generally  too  brief  and  mild  to  require 
treatment,  but  when  severe,  it  should  be  treated  like  or- 
ganic angina. 


CHAPTER  II. 


NEPHRITIS. 

CLASSIFICATION. 

1.  Acute   Renal   Irritation. 

2.  Acute  Nephritis.  I.   Allied   Conditions. 

3.  Chronic  Nephritis. 

4.  Syphilitic   Nephritis. 

5.  Arteriosclerotic  Degeneration. 

6.  Passive  Congestion. 

NOTES  ON  CLASSIFICATION. 

This  classification  aims  to  separate  only  the  more  im- 
portant types  of  nephritis  which  can  be  recognized  clin- 
ically and  which  require  different  treatment. 

Acute  renal  irritation,  acute  nephritis  and  chronic  ne- 
phritis appear  to  be  allied  diseases.  The  gaps  between 
them  are  bridged  by  intermediate  forms  and  the  acute  in- 
fectious diseases  are  responsible  for  most  cases  of  these 
three  types  of  renal  inflammation.  Toxic  irritation  differs 
from  acute  nephritis  mainly  in  degree,  and  chronic  ne- 
phritis from  acute  nephritis  in  that  instead  of  recovering 
it  progresses,  though  it  may  be  slowly. 

Although  arteriosclerotic  degeneration  is  essentially  dif- 
ferent from  chronic  nephritis,  the  latter  being  primarily 
an  inflammation  of  the  kidney  and  the  former  being  a  de- 
generation secondary  to  vascular  disease,  the  two  are  often 
combined.  In  such  combinations  either  process  may  pre- 
dominate. 

Besides  intermediate  or  mixed  forms  of  nephritis  there 
are  the  rare  amyloid  degeneration  and  a  variety  of  forms 
difficult  to  classify. 

43 


45 


DIFFERENTIATION    OF    TYPES    OF    NEPHRITIS. 

Acute  Renal  Irritation  is  distinguished  from  acute  ne- 
phritis by  less  profound  changes  in  the  urine,  absence  of 
symptoms  of  renal  insufl&ciency  and  prompt  recovery  after 
removal  of  the  cause.  It  is  frequently  symptomatic  in 
acute  fevers. 

Acute  Nepliritis  is  common  in  childhood  and  youth.  It 
is  generally  traceable  to  an  acute  infectious  disease,  is 
often  found  after  scarlet  fever  and  may  follow  tonsillitis  or 
result  from  an  irritant  poison.  Acute  nephritis  differs 
much  in  severity  and  consequently  in  signs  and  symptoms. 
Severe  cases  may  show  anuria  or  marked  oliguria  with 
anasarca  and  perhaps  uremia.  The  urine  in  these  cases  is 
loaded  with  blood,  albumen,  casts  and  fat,  and  that  of  mild 
conditions  contains  the  same  elements  in  smaller  amount. 
Blood-pressure  may  be  moderately  elevated,  and  if  the  dis- 
ease persists  for  some  weeks,  left  ventricular  hypertrophy 
may  develop. 

Chronic  Nephritis.  The  etiology  is  like  that  of  acute 
nephritis,  as  a  rule,  but  there  are  some  cases  arising  from 
chronic  toxemias. 

Stages.     1.  Early. 


„    _  ,        ,      ,  _,  a.  Latent. 

2.  Subacute.  \.  Phases.        ,  ^  ,    ^. 

„    _,        .        f  d.  Exacerbation. 

3.  Chronic. 

The  course  of  the  disease  may  run  from  a  few  years  or 
less  to  twenty  years  or  more.  Any  stage  may  be  without 
symptoms.  The  early  stage  may  be  indistinguishable 
from  acute  nephritis,  and  exacerbations  may  be  mistaken 
for  acute  nephritis.  Left  ventricular  hypertrophy  and 
hypertension  develop  gradually  and  there  is  a  progressive 
fall  in  the  specific  gravity  of  the  urine  associated  with  an 
increase   in  the   amount   of   urine. 

The  late  stage  shows  marked  left  ventricular  hyper- 
trophy, a  blood-pressure  generally  over  200  mm.  of  mercury 
and  a  urine  of  very  low  gravity,  containing  little  or  no 
albumen  and  a  scanty  sediment.  At  this  stage  many  of 
the  glomeruli  and  much  of  the  parenchyma  has  been  re- 
placed by  connective  tissue,  and  shrinkage  has  followed  so 
that  the  kidneys  are  much  diminished  in  size.     The  chief 


47 

dangers  are  from  uremia  or  from  cardiac  insufficiency  sec- 
ondary to  hj^pertension.  In  the  absence  of  arteriosclerosis 
a  provisional  diagnosis  of  chronic  nephritis  may  often  he 
made  by  the  evidence  of  hypertension  and  of  cardiac  hyper- 
trophy. Cases  of  chronic  nephritis  complicated  with  ar- 
teriosclerosis are  liable  to  apoplexy. 

Syphilitic  NepFiritis  is  generally  regarded  as  an  unusual 
form  of  acute  nephritis.  It  occurs,  according  to  Osier,  most 
commonly  in  the  secondary  stage  of  syphilis  within  six 
months  of  the  primary  lesion  and  it  resembles  other  toxic 
nephritis.  Gumma  of  the  kidney  is  rarely  seen  but  it  is 
probable  that  some  instances  of  renal  arteriosclerosis  are 
of  syphilitic  origin.  Signs  of  an  active  syphilis  in  the 
presence  of  a  nephritis  suggest  but  do  not  prove  that  the 
two  are  related. 

Arteriosclerotic  Degeneration  of  the  kidney  is  most  com- 
mon in  old  age.  It  may  be  part  of  a  widespread  arterio- 
sclerosis or  it  may  be  manifested  chiefly  in  the  kidney. 
There  occurs  a  non-inflammatory  destruction  of  parts  of 
the  kidney  dependent  on  sclerosis  of  the  arteries  supplying 
those  parts.  Local  shrinkage  and  irregularity  or  rough- 
ness  of   the   surface   results. 

The  urine,  at  first,  may  show  considerable  albumen  and 
some  blood  and  casts.  Later  it  resembles  that  of  chronic 
nephritis.  Hypertension  and  left  ventricular  hypertrophy 
are  generally  well  marked  in  the  later  stages  of  renal  de- 
generation. 

The  greatest  dangers  are  from  cardiac  insufficiency  or 
cerebral  hemorrhage.  Typical  uremia  occurs  rarely  if  at 
all  in  pure  degenerative  cases  but  there  is  often  more  or 
less  chronic  nephritis  combined  with  the  degenerative 
lesions.  Chronic  lead-poisoning,  gout  or  syphilis  may  be 
important  etiologically. 

Passive  Congestion  is  secondary  to  congestion  in  the 
venous  circulation.  Therefore,  it  is  commonly  symptomatic 
of  cardiac  insufficiency.  The  urine  is  high  colored,  scanty 
and  of  a  high  gravity.  Albumen  and  casts  are  found,  vary- 
ing in  amount  and  number.  There  are  no  definite  symp- 
toms, and  the  urine  clears  rapidly  after  removal  of  the 
congestion. 


49 

Passive  congestion  may  mask  an  acute  nephritis,  espe- 
cially in  the  active  stage  of  endocarditis. 

ACUTE  RENAL  IRRITATION. 

Treatment.  The  signs  of  irritation  can  be  much  reduced 
by  the  free  administration  of  water.  The  water  dilutes  the 
irritating  substance  and  promotes  excretion  by  stimulating 
diuresis.     No  other  direct  treatment  is  needed. 

Caution.     Make  sure  that  a  nephritis  is  not  developing. 

ACUTE  NEPHRITIS. 

PRINCIPLES  OF  TREATMENT. 

A.  Reduce  the  demands  on  the  kidney  by: 

1.  Rest  in  bed. 

2.  Elimination  by  other  channels.     /,,^   ^ 

\{h)   Purging. 

3.  Suitable  diet. 

4.  Limitation  of  liquids  in  suitable  cases. 

B.  Maintain  nutrition. 

(7.  Avoid  exposure  to  cold  or  to  sudden  cooling. 
D.  Drugs  should  be  used  only  when  indicated;   never  by 
routine. 

METHODS  OF  TREATMENT. 

Sweating,     1.  Hot-air  bath  in  bed  or  chair. 

2.  Hot  tub-bath. 

3.  Hot  wet  pack. 

4.  Electric  light  bath. 

5.  Turkish  or  Russian  bath. 

Hot-air  baths  are  best  given  in  bed.  If  the  baths  cause 
profuse  sweating  they  may  be  used  daily  for  an  hour  or 
more.  If  sweating  does  not  begin  promptly  a  drink,  hot 
or  cold,  may  start  it,  or  pilocarpine  may  be  administered 
subcutaneously.  Pilocarpine  may  cause  pulmonary  edema 
and  is,  therefore,  contraindicated  when  the  heart  is  weak, 
the  lungs  congested,  or  the  patient  unconscious.  Some 
patients  who  sweat  little  at  first  respond  well  to  subsequent 
baths. 


t>l 


If  sweating  cannot  be  induced,  if  the  pulse  becomes 
weak,  or  if  the  patient  develops  cardiac  symptoms  during 
a  bath  the  baths  must  be  given  up.  They  should  not  be 
ordered  for  an  unconscious  patient  without  consideration 
followed  by  close  observation. 

Hospitals  provide  apparatus  for  the  hot-air  bath.  In 
private  houses  it  can  be  improvised  with  barrel-hoops  or 
strong  wire  to  arch  the  bed,  an  oilcloth  from  the  kitchen 
table  as  a  rubber  sheet,  an  elbow  of  stovepipe  and  a 
kerosene  lamp  to  provide  the  heat;  or  the  patient,  without 
clothing,  may  sit  in  a  cane-bottomed  chair  under  which 
stands  a  small  lamp.  Blankets  are  then  wrapped  around 
the  chair  and  the  patient  together,  leaving  no  hole  for  the 
heat  to  escape. 

Care  must  be  taken  not  to  set  the  blankets  on  fire. 

Purgation.  Obtain  watery  catharsis  to  reduce  edema  and 
to  increase  elimination  of  toxic  material  by  the  intestinal 
tract.  Magnesium  sulphate,  or  compound  jalap  powder 
with  additional  potassium  bitartrate,  or  elaterium  are  good 
for  this   purpose    (p.    163). 

In  the  absence  of  edema,  purgation  should  not  be  ex- 
cessive, lest  the  patient's  nutrition  suffer. 

Diet.  Proteids,  meat  broths,  spices,  acids  and  alcohol 
irritate  the  kidney  and  are  to  be  avoided  during  the  acute 
stage. 

Milk  is  an  exception  to  the  rule  against  proteid  because 
experience  shows  that  it  is  not  injurious.  A  diet  exclu- 
sively of  milk  becomes  monotonous  if  long  continued  and 
such  large  quantities  are  needed  to  maintain  nutrition  that 
the  fluid  part  may  tend  to  increase  edema.* 

Salt  seems  not  to  be  harmful  as  a  rule.  When,  however, 
edema  persists  in  spite  of  other  treatment,  a  "  salt-free " 
diet  may  be  tried,  i.e.;  salt  is  not  to  be  added  to 
food  either  before  or  after  cooking.  This  change  is  fol- 
lowed occasionally  by  rapid  disappearance  of  the  edema. 
If  deemed  advisable  the  phosphate  t   in  milk  can  be  pre- 


*  Three  quarts  of  milk  furnish  about  2000  calories  -which  is  scant 
for   an  adult. 

t  One  liter  of  milk  contains  3.80  gm.  of  phosphate  and  1.79  gm.  of 
chlorides;    Sommerfeld,    "  Handb.   d.   Milchkunde,"   p.   271. 


53 


cipitated  by  adding  5  gr.  (or  0.3  gm.)  of  calcium  carbonate 
per  pint  of  milk. 

Diet  List  (incomplete).  Milk,  cream,  butter,  sugar,  jun- 
ket, ice  cream,  bread,  toast,  cereals,  rice,  potato,  macaroni, 
sago,  tapioca,  spinach,  lettuce,  sweet  raw  fruits  or  stewed 
fruits. 

In  convalescence  enlarge  diet  cautiously  on  account  of 
danger  of  relapse.  When  returning  to  proteid  foods  allow 
eggs  first,  then  fish  and  lastly  meat,  red  or  white. 

Liquids,  including  liquid  foods,  should  be  limited  strictly 
when  there  is  anasarca  or  when  they  are  not  being  fully 
excreted.  One  pint  in  twenty-four  hours  may  be  enough. 
Cracked  ice  may  be  used  for  thirst,  but,  if  the  patient 
suffers,  more  liquid  should  be  allowed. 

Water  is  an  excellent  diuretic  when  freely  excreted.  It 
dilutes  irritating  substances  and  favors  their  elimination. 

Nutrition.  The  quantity  of  food  to  be  prescribed  depends 
on  the  severity  of  the  nephritis,  the  physical  strength,  and 
the  state  of  nutrition  of  the  patient.  Strong,  well-nour- 
ished patients  having  severe  nephritis  may  benefit  by  star- 
vation for  a  day  followed  by  very  small  quantities  of  food 
for  several  days.  A  feeble,  emaciated  and  anemic  person 
should  receive  food  enough  to  maintain  body-weight. 

Exposure.  To  prevent  chill,  keep  room  at  equable  temper- 
ature and  let  patient  wear  flannel  or  lie  between  blankets. 

Medication.  Irritating  diuretics,  such  as  calomel,  are 
dangerous  in  all  forms  of  nephritis. 

Theobromine,  theocine  and  apocynum  are  useless  and 
may  perhaps  do  harm  in  acute  nephritis. 

Mild  saline  diuretics  or  alkaline  mineral  waters  may  be 
valuable,  particularly  in  convalescence,  but  it  may,  perhaps, 
be  wiser  to  avoid  them  in  severe  cases  during  the  early 
stage. 

For  anemia,  iron  may  be  tried,  e.g.,  Blaud's  Pill,  or 
Basham's  Mixture  (Liquor  ferri  et  ammonii  acetatis  N.  F.) 
which  contains  iron  and  acts  also  as  a  mild  diuretic. 

Prophylaxis.  If  it  appears  that  the  tonsils  were  the 
point  of  entrance  or  the  original  seat  of  disease  their  re- 
moval at  a  suitable  time  should  be  advised. 

Uremia.     For  treatment  see  p.  59. 


55 

CHRONIC  NEPHRITIS. 

PRINCIPLES  OF  TREATMENT. 

1.  Adequate  nourishment  is  essential  iDecause  the  disease 
is  chronic  and  a  cure  not  to  be  expected. 

2.  Limit  demands  on  the  kidney  and  guard  against 
uremia  by   (a)   diet,  (&)   elimination. 

3.  Guard  against  cardiac  insufficiency  by  avoiding  physi- 
cal and  mental  strain. 

4.  Avoid  exposure  to  cold. 

METHODS. 

Methods  are  the  same  in  general  as  for  acute  nephritis, 
but  they  must  be  used  with  regard  to  the  condition  of  the 
patient  and  the  stage  and  severity  of  the  disease. 

The  Early  Stage,  when  severe,  must  be  treated  as  acute 
nephritis  until  recognized  as  chronic.  Nutrition  then  be- 
comes a  more  important  problem. 

Exacerbations  are  treated  like  acute  nephritis  except  that 
nutrition  is  more  important  than  in  acute  nephritis  and 
therefore  diet  should  be  more  liberal. 

Latent   phase;    early,   subacute,  or  chronic: 

1.  Restrict  the  following: 

(a)   Meats.  (d)   Alcohol. 

(&)   Meat  broths.  (e)   Acids, 

(c)   Spices. 

2.  To  favor  elimination  of  toxic  material  the  following 
may  be  advised: 

(a)  A  saline  cathartic  every  second,  third,  or  fourth 
day.     Bowels  must  be  kept  free. 

(&)  Hot  tub-baths,  Russian,  or  Turkish  baths  twice 
weekly. 

(c)   Alkaline  mineral  waters  with  meals. 

3.  Uremia.     For  treatment   see  p.    59. 

4.  Cardiac  Insufficiency.  For  treatment  see  hyperten- 
sion p.  25. 


57 


SYPHILITIC  NEPHRITIS. 

1.  Apply  principles  advised  for  acute  or  chronic  nephritis 
according  to  the  severity  and  symptoms  of  the  case. 

2.  Iodide  and  mercury  or  salvarsan  should  be  used  in 
small  doses. 

3.  Watch  urine  and  omit  mercury  if  renal  irritation  in- 
creases under  treatment.  When  the  diagnosis  is  correct 
the  urine  generally  improves  promptly.  As  there  are  no 
characteristic   signs  mistakes   of   diagnosis   easily   oc'cur. 

ARTERIOSCLEROTIC  RENAL  DEGENERATION. 
TREATMENT. 

1.  Search  for  a  cause  of  arteriosclerosis.  If  such  can  he 
found  and  if  it  is  believed  still  to  be  operative  treat  it  ap- 
propriately. 

Such  causes  are,  e.g.,  {a)  chronic  lead-poisoning;  (6) 
gout;    (c)    syphilis;    id)    prolonged  worry. 

2.  Nutrition  must  be  maintained. 

3.  Limit  the  demands  on  the  kidney  by  moderate  restric- 
tion of: 

(a)   Meats.  {d)  Alcohol. 

(&)   Meat  broths.  (e)   Acids, 

(c)   Spices. 

4.  Avoid  physical  and  mental  strain  to  guard  against 
{a)   cardiac  insufficiency;    (ft)   cerebral  hemorrhage. 

5.  Cardiac  insufficiency,  when  present,  should  be  treated 
with  reference  to  its  probable  cause,  e.g.: 

{a)   Degenerative  valve  lesion,  p.  25. 
(ft)   Degenerative  myocardial  lesion,  p.  39. 
(c)   Hypertension,  p.  25. 

6.  Mild  toxemia  may  clear  up  under  cardiac  treatment  if 
the  heart  is  at  fault. 

Alkaline  diuretics  may  be  of  use. 

Methods  advised  for  uremia  may  be  used  if  toxemia  be 
severe. 

PASSIVE    CONGESTION    OF    THE    KIDNEY. 

The  treatment  is  that  of  the  cause  of  the  stasis. 


59 


UREMIA. 

Note. — ■Uremia  is  an  intoxication  of  unknown  nature, 
common  in  severe  acute  nephritis  and  in  chronic  nephritis, 
and  particularly  so  in  exacerbations  of  the  subacute  stage 
of  chronic  nephritis. 

Symptoms  vary  much  in  degree.  There  may  be  mental 
sluggishness,  drowsiness  or  coma,  loss  of  appetite,  nausea 
or  vomiting,  muscular  twitchings  or  convulsions,  head- 
ache, delirium,  disturbance  of  vision,  transient  ocular 
paralysis,  paresis  of  the  extremities  or  paroxysmal  dysp- 
noea. The  urine  is  usually  scanty  or  suppressed.  Retinitis 
and  Cheyne-Stokes  respiration  are  common.  The  onset 
may  be  gradual,  and  with  slight  signs,  or  relatively  acute 
and  severe.     Edema  may  be  present  or  absent. 

Methods  of  Treatment. 
For  mild  uremia: 

1.  Diet  as  for  mild  acute  nephritis. 

2.  Eliminative  measures. 

(a)  Purgation. 

(&)  Sweating. 

(c)  Water  if  there  is  little  or  no  edema. 

id)  Saline  diuretics. 

Severe  uremia: 

1.  Diet  should  be  much  restricted  in  quantity  and  quality 
as  for  severe  acute  nephritis.  Vomiting  or  unconsciousness 
may  prevent  feeding  for  a  time. 

2.  Water  should  be  used  freely  unless  there  be  much 
edema.  If  water  cannot  be  taken  by  mouth  it  can  be  used 
as  salt  solution  by: 

(1)  Hypodermoclysis. 

(2)  Intravenously. 

(3)  By  rectum,   (a)   Enema. 

(&)   Seepage. 

3.  Purgation.  Magnesium  sulphate,  or  other  purgatives 
(p.  163)  may  be  used.  Croton  oil  is  useful  especially  for 
unconscious   patients.     If   rubbed   up   with   a   little   butter, 


61 


made  into  a  ball  and  placed  on  the  back  of  the  tongue,  it 
will  be  swallowed.  Repeated  doses  of  purgatives  should 
be  employed,  if  needed,  to  obtain  prompt  and  profuse 
watery  catharsis,  but  when  there  is  no  edema,  excessive 
purgation  may  tend  to  concentrate  toxins,  and  may  thus 
do  harm,  unless  counteracted  by  free  administration  of 
water. 

4.  Sweating  often  does  good.  Hot-air  baths  may  be  used 
daily  if  they  cause  profuse  sweating.  They  should  not  be 
ordered  for  an  unconscious  patient.  Pilocarpine  should 
not  be  used  if  there  is  pulmonary  edema,  cardiac  insuf- 
ficiencj^  or  unconsciousness. 

5.  Venesection,  A  pint  or  more  of  blood  may  be  with- 
drawn from  a  vein  at  the  elbow  by  incision,  or,  if  a  suit- 
able apparatus  be  at  hand,  by  aspiration. 

Opinion  is  divided  as  to  the  need  or  value  of  injecting 
salt  solution  after  bleeding.  Ordinarily,  patients  do  well 
without   it. 

6.  Colon  irrigations  with  large  quantities  of  hot  water 
may  be  tried  in  the  hope  of  promoting  elimination  of  tox- 
ins. 

7.  Drugs.  The  use  of  nitroglycerin  or  other  vaso-dila- 
tors  is  followed  frequently  by  pronounced  diuresis  in  pa- 
tients having  hypertension.     The  effect  is  transient. 

Morphine  may  be  given  subcutaneously  for  convulsions. 

Saline  diuretics,  e.g.  "  Cream  of  tartar  water,"  *  Pot. 
citrate,  or  "  Basham's  mixture,"  may  be  of  use  when  the 
severe  symptoms  have  subsided. 

Heart  stimulants  are  indicated  when  there  is  cardiac  in- 
sufficiency, p.  15. 


*  A  sat.  sol.  of  Pot.  bitartrate,  the  strength  of  which  is  1  in  201, 
equal  to  about  40  grs.  in  a  pint,  or  to  3  gm.  in  500  c.c.  of  water. 
Lemon   juice   or  lemon  peel   can  be  used  for  flavoring. 


CHAPTEE  III. 


ACUTE  INFECTIOUS  DISEASES. 
PRINCIPLES  OF  TREATMENT. 


1.  Rest  in  bed 


a.  To  conserve  strength. 

ft.  To  reduce  metabolic  waste. 


2.  Ingestion  of  much  water 


3.  Bowels  should  be  kept  clear 


a.  To  dilute  toxins. 
&.  To   favor  their   elimina- 
tion. 
a.  To  favor  digestion. 
&.  To     prevent     absorp- 
tion  of   toxic    sub- 
stances. 


4.  Good  nursing  < 


a.  To   secure   cleanliness. 
&.  To  conserve  strength. 

c.  To  promote  comfort. 

d.  To    afford    accurate    information 

physician. 

e.  To  facilitate  treatment. 


to 


5.  Diet  should  be  -< 


fa.  Easy  to   swallow, 
&.  Easily  digestible. 

c.  Nutritious  but  not  bulky. 

d.  Palatable  and  varied. 


6.  Meals  should  be  - 


'a.  Frequent  and  small  to  favor  diges- 
tion. 
h.  Commensurate    in    quantity    with 
digestive  power. 

7.  The  sick-room  should  be  well  ventilated. 

8.  Infection  of  others  must  be  prevented. 

9.  Symptoms  should  be  treated  as  they  arise  with  regard 
to  the  circumstances  of  the  case. 

63 


65 


TYPHOID  FEVER. 

Notes.—  Typhoid  is  characterized  pathologically  by  pe- 
culiar ulceration  of  the  small  intestines.  Ulceration  is 
less  frequent  in  the  colon  and  is  rare  in  the  rectum. 

Typhoid  bacilli  enter  the  blood,  the  organs,  the  secre- 
tions, and  the  excretions. 

The  disease  is  self-limited,  lasting  from  two  weeks  to  three 
months.  Relapses  are  common  and  complications  frequent. 
Toxemia  is  often  severe. 

COMMON  CAUSES  OF  DEATH. 

1.  Toxemia. 

2.  Exhaustion. 

3.  Severe  complications. ' 

(fl)    Perforative  peritonitis. 
(?))   Repeated  hemorrhages. 

PRINCIPLES  OF  TREATMENT  FOR  TYPHOID. 

A.  Prevent  infection  of  ethers. 

B.  Dilute  toxins  and  favor  their  elimination. 

C.  Conserve  strength  of  the  patient. 

D.  Diet  should  be  suited  to  the  individual  as  well  as  to  the 
disease. 

E.  Drugs  are  to  be  prescribed  for  definite  reasons  only  and 
not  to  reduce  the  fever. 

F.  Observe  the  patient's  condition  closely  and  modify  treat- 
ment promptly  when  indicated. 

G.  Have  the  best  nursing  available  and  if  possible  have  a 
day-nurse  and  a  night-nurse. 

H.  Treat  symptoms  and  complications  v^ath  due  regard  to 
other  circumstances  of  the  case. 

ROUTINE  ORDERS  TO  NURSE. 

1.  Enteric   precautions. 

2.  Dr.  Shattuck's  enteric  diet.     (Prof.  F.  C.  Shattuck.) 

3.  Baths  as  directed  every  four  hours,  p.r.n. 

4.  Suds  enema  every  other  day  or  p.r.n. 

5.  Spray  throat  and  wash  mouth  and  eyes  every  four 
hours. 


G7 


6.  Hexamethylenamine,  5  grs.  (or  0.3  gm.)  t.i.d. 

7.  Record  temperature,  pulse  and  respiration  every  four 
hours,  the  daily  excretion  of  urine,  and  the  amount  of  food 
and  water  ingested. 

Specific  directions  for  diet  and  baths  should  be  given  with 
due  regard  for  the  circumstances  of  each  case.  Frequent 
modification  may  be  required. 

METHODS  OF  TREATMENT  FOR  TYPHOID. 

A.   Prophylaxis. 

I.  Prophylactic  inoculation  should  be  required  for  those 
coming  into  intimate  contact  with  the  patient  (p.  177). 

II.  "  Enteric   precautions." 

1.  Isolation  of  the  patient  is  desirable. 

2.  Flies  must  be  excluded. 

3.  Those  who  touch  the  patient  should  wash  their 

hands   promptly. 

4.  Eating  utensils  should  be  reserved  exclusively  for 

the  patient  and  washed  and  kept  apart. 

5.  Sheets  and  other  linen  when  removed  from  the 

sick-rocm  should  be  soaked  in  5  per  cent  carbolic 
acid  for  at  least  half  an  hour,  or  boiled. 

6.  The  best  method  of  dealing  with  faeces  *  is  that  of 

Kaiser,  of  Groty.  "  It  consists  of  adding 
enough  hot  water  to  cover  the  stool  in  the  re- 
ceptacle and  then  adding  about  14  of  the  entire 
bulk  of  quicklime  (calcium  oxide),  covering  the 
receptacle  and  allowing  it  to  stand  for  two 
hours." 

Urine    can   be    treated    similarly   by    adding 
enough  quicklime  to  bring  it  to  a  boil. 

7.  Bath  water  may  be  boiled  after  using  when  practi- 

cable, but  is  not  worth  while  where  plumbing  is 
good. 

8.  Cleanliness   of   the   attendant   is   essential. 


*  H.    Linenthal:    Monthly    Bui.    Mass.    State    Board   of    Health,    Jan., 
1914. 


69 


B.  Dilution  and  Elimination  of  Toxins. 

1.  The  urinary  output  should  be  kept  above  GO  oz.  in  24 
hours  by  free  administration  of  water.  A  much  larger  quan- 
tity of  urine  can  be  obtained  but  it  is  a  question  whether 
water  taken  in  very  large  quantities  may  not  favor  hemor- 
rhage. Liquids,  including  liquid  foods,  should  total  about 
three  quarts  daily. 

2.  The  bowels  should  be  kept  clear.  If  they  do  not  move 
freely  suds  enemata  may  be  employed  as  often  as  necessary. 
Cathartics  are  to  be  avoided  as  a  rule  during  the  ulcerative 
stage  because  excessive  peristalsis  may  favor  hemorrhage  or 
perforation. 

C.  Conservation  of  Strength.     Very  important  because  of  the 

long  average  duration  of  typhoid. 

1.  The  nurse  should  feed  the  patient,  turn  him  over,  al~ 
low  him  to  do  nothing  for  himself  and  should  make  him 
comfortable. 

2.  The  maximum  of  nutrition  should  be  maintained  by  fre- 
quent feedings. 

3.  Visitors  should  be  excluded  entirely  as  a  rule. 

D.  Diet. 

Dr.  Shattuck's  principle  in  choosing  a  diet  has  been  stated 
by  him  as  follows:  "Feed  with  reference  to  digestive  power 
rather  than  name  of  disease,  avoiding  such  articles  of  diet 
as  might  irritate  ulcerated  surfaces." 

Requirements: 

1.  Nutritious  but  not  bulky. 

2.  Easily   digestible. 

3.  Non-irritating  to  intestine. 

4.  Quantity  commensurate  to  digestive  power. 

5.  Adapted  to  the  patient's  condition. 

6.  Palatable  and  varied. 

IVieals  should  be  frequent,  at  least  once  in  four  hours. 
If  the  patient  can  take  little  at  a  time  he  should  be  fed 
every  two  hours  or  even  every  hour. 

Diet  List.  An  enteric  diet  may  include  the  following 
foods  and  any  others  that  conform  to  the  requirements 
stated  above:  liquid  foods,  strained  cereals,  custard,  blanc- 
mange, junket,  simple  ice  cream,  soaked  toast  without  the 


71 


crustj  bread  or  crackers  in  milk,  soft  eggs,  oysters  without 
the  heel,  finely  minced  chicken,  etc. 

Coleman  has  shown  that,  by  the  free  use  of  milk-sugar  and 
of  cream,  loss  of  weight  in  typhoid  may  sometimes  be  pre- 
vented. The  cream  can  be  added  to  milk  or  to  other  foods. 
Milk-sugar  can  be  added  to  liquids,  in  the  proportion  of  Y2 
oz.  in  4  oz.  (or  15  c.c.  in  120  c.c.)  of  liquid.  Coleman's  diet, 
if  used  indiscriminately,  may  perhaps  cause  death. 

Departure  from  routine  diet  may  be  required  for  various 
reasons,  e.g. 

1.  Patient  tco  weak  to  swallow  solid  food. 

2.  Vomiting. 

3.  Persistent  diarrhoea,  often  due  to  milk. 

4.  Severe  distension,  often  due  to  milk. 

Advantages  of  a  liberal  diet. 

1.  Weight  and  strength  are  better  maintained. 

2.  Toxemia  is  less. 

3.  Distension  is  uncommon. 

4.  Convalescence  is  shorter. 

5.  Patients  suffer  less. 

E.  Medication.  Hexamethylenamine  (p.  169)  should  be  pre- 
scribed by  routine  as  a  urinary  antiseptic.  It  may,  rarely, 
cause  hematuria  or  painful  micturition.  It  should  then  be 
omitted  for  a  few  days  and  resumed  in  smaller  dosage. 

Other  drugs  may  be  ordered  occasionally  for  special  symp- 
toms as  required. 

Antipyretics  should  not  be  prescribed  to  reduce  fever,  but 
they  may  be  used  for  headache,  in  the  early  stages  of  ty- 
phoid. Being  depressants  they  are  dangerous  when  circu- 
lation is  impaired. 

F.  Observation. 

I.  Examine  the  patient  once  or  more  daily  during  the 
febrile  stage. 

Look  for: 

1.  Signs  of  circulatory  weakness. 

2.  Pulmonary  hypostasis. 

3.  Bed    sores. 

4.  Changes  in  the  condition  of  the  abdomen. 


73 


(a)   Distension  of  abdomen. 
(&)    Spasm. 

(c)  Tenderness. 

(d)  Distension   of   bladder    from    retention. 

II.  Keep  track  of: 

1.  Urinary  excretion. 

2.  Nourishment.  t 

3.  Account    for    changes    in    pulse    or    temperature. 

They  may  be  the  first  sign  of  hemorrhage   or 
perforation. 

4.  Keep  sterile  salt-solution  ready  for  use  by  hypo- 

dermoclysis  or  intravenously  in  case  of  need. 

III.  It  is  the  duty  of  the  physician  carefully  to  supervise 
treatment  during  the  period  when  hemorrhage  or  perfora- 
tion may  occur,  and  he  himself  or  his  assistant  should  be 
accessible  at  times  when  emergencies  may  arise. 

G.  Convalescence.     In  the  convalescence  free  evacuation  of 
the   bowels   is   important. 
Massage  may  hasten  return  of  strength. 

H.    Nursing. 

The  nurse's  general  duties  are  to  do  her  utmost  to  spare 
the  patient  exertion,  discomfort  and  mental  unrest;  to  re- 
port to  the  physician  at  his  visit  all  changes  in  the  condi- 
tion of  the  patient;  to  be  prepared  to  answer  questions  as 
to  the  effect  of  treatment  prescribed;  and  to  notify  the  phy- 
sician at  once  of  alarming  symptoms  or  signs  suggesting 
severe  hemorrhage  or  perforation.  She  should  know  the 
possible  significance  of  sudden  changes  in  pulse  rate  and 
temperature  and  should  look  for  blood  in  every  fcecal  de- 
jection. To  prevent  accident  she  should,  as  far  as  possible, 
avoid  leaving  the  patient  alone  even  when  he  is  not  ap- 
parently delirious. 

The  following  complications  can  generally  be  prevented 
by  an  experienced  nurse:  — 

1.  Bed   sores.  5.  Boils. 

2.  Corneal  ulceration.  6.  Cracked  lips. 

3.  Middle-ear  infection.  7.  Tender  toes. 

4.  Parotitis.  8.  Hypostatic  congestion. 


75 


1.  To  prevent  bed   sores:  — 

(a)   Keep   sheets   smooth,   clean   and   dry. 

(&)   After  soiling,  clean  the  skin  promptly,  dry  it,  rub 

in    zinc    oxide    ointment,    and    powder    with 

starch. 

(c)  Change  the  patient's  position  occasionally. 

(d)  Do  not  allow  prolonged  pressure  on  bony  promi- 

nences. 

(e)  If  a  red  spot  appears  where  there  has  been  pres- 

sure keep  pressure  off  that  part  by  rings  or 
pads  and  paint  the  spot  with  picric  acid,  1%. 

2.  To  prevent  corneal  ulceration  keep  cornea  clean  by 
bathing  the  eyes  every  four  hours  with  a  2%  watery  solu- 
tion of  boric  acid. 

3.  Boils  in  crops  are  generally  due  to  the  use  of  dirty 
sponges.  If  a  boil  appears  care  must  be  taken  to  avoid 
spreading  the  infection. 

4.  Cracked  lips  can  be  prevented  by  the  use  of  cold  cream. 

5.  Middle-ear  infection  or  parotitis  may  result  from  im- 
proper care  of  the  mouth.  The  mouth  should  be  cleaned 
and  the  throat  sprayed  every  four  hours  with  a  non-irri- 
tating antiseptic.  Dobell's  solution,  or  "  alkaline  antisep- 
tic "  will  serve,  diluted,  if  necessary,  with  one  or  two  parts 
cf  water  to  avoid  irritation  of  the  mucous  membranes.  Ex- 
cessive dryness  of  the  tongue  from  mouth  breathing  can  be 
prevented  by  the  use  of  vaseline. 

6.  Hypostatic  congestion  of  the  bases  of  the  lungs  is  due 
in  part  to  protracted  lying  in  one  position.  It  can  be  com- 
bated, if  not  prevented,  by  rolling  the  patient  on  one  side 
and  supporting  him  in  this  position  for  an  hour  or  more  by 
means  of  a  pillow.  The  patient  should  then  be  rolled  onto 
the  other  side  for  another  period  of  time,  and  these  man- 
oeuvres should  be  practiced  at  least  once  daily. 

SYMPTOMATIC  TREATMENT  FOR  TYPHOID. 

Fever   and    Toxemia. 

Hydrotherapy  generally  acts  well. 
Benefits  expected  from  it  are: 

1.  Fall  of  temperature  of  from  1  to  2  degrees. 


77 


2.  Fall  in  rate  with  increase  of  force  and  volume  of  the 
pulse. 

3.  Deei:er  breathing  and  diminution  of  pulmonary  hypo- 
stasis. 

4.  Better  sleep. 

5.  Diminution  of  symptoms  of  toxemia. 

Routine  bath  order.  For  temperature  *  of  103.5°  rectal 
give  bath  every  four  hours  at  85°.  For  every  half  degree 
of  temperature  above  103.5°  lower  temperature  of  bath- 
water 5°, 

Rules  for  use  of  baths: 

1.  Baths  should  be  ordered  for  definite  indications  only. 

2.  For  children  and  for  thin  and  feeble  patients,  baths 
should  be  warmer  and  shorter  than  for  the  robust  adult. 

3.  The  physician  should  supervise  the  first  bath  and  pre- 
scribe subsequent  baths  with  regard  to  the  effect  of  the  first 
one. 

4.  If  the  pulse  gets  weaker  the  bath  should  be  stopped. 

5.  Much  cyanosis  or  shivering  after  the  bath  indicates  that 
it  was  too  cold,  or  too  long,  or  that  not  enough  friction  was 
used. 

6.  Stimulants  are  seldom  required  before  or  after  a  bath 
that  is  suited  to  the  case  and  well  given. 

7.  Baths  must  be  modified  or  omitted  if  they  greatly  excite 
the  patient,  interfere  with  sleep,  or  cause  a  rise  of  tempera- 
ture. 

Methods  of  bathing: 

"  M.  G.  H.  Typhoid  Bath."  With  rubber  sheet,  supported 
at  edges  by  rolls  of  blanket  make  tub  in  bed  of  patient. 
Dash  water  over  him,  and  rub  vigorously  in  turn,  with  the 
hands,  the  chest,  limbs,  and  back,  but  not  the  abdomen.  The 
duration  of  the  bath  should  be  20  minutes  or  less  if  so  or- 
dered. 

Sponge  baths  often  act  well  and  are  preferred  in  many 
cases.     A  mixture  of  equal  parts  of  alcohol  and  2  %  boric 


*  Temperatures  in  typhoid  are  best  taken  by  rectum  because  these 
are  more  reliable  than  mouth  temperatures.  The  rectal  temperature 
averages    about    1°    higher    than    the   mouth   temperature, 


79 


acid  solution  in  water  at  the  required  temperature  can  be 
used  for  bathing. 

CIRCULATORY  WEAKNESS.* 

I.  Cardiac  weakness  may  be  caused  by  various  conditions 
which  are  difficult  to  distinguish  from  one  another,  e.g., 

1.  Exhaustion  or  lack  of  nourishment. 

2.  Preexisting  cardiac  lesions. 

3.  Deranged  nervous  control. 

4.  Cloudy  swelling. 

5.  Fresh  endo-,  myo-  or  pericarditis. 

Syniptoms  generally  develop  gradually  so  that  there  is 
plenty  of  time  to  prescribe. 

Stimulants  may  be  ordered  if  the  pulse  becomes  weak  or 
irregular  or  goes  above  120.  They  may  act  well  or  not  at 
all,  and  their  use  must  often  be  tentative. 

Digitalis,  strychnine,  caffeine  or  other  drugs  may  be  tried. 

Emaciated  or  septic  patients  taking  little  food  may  do  well 
on  alcohol.  It  seems  sometimes  to  act  as  a  food,  and  in- 
directly  as   a   stimulant. 

II.  Vasomotor  paresis  (p.  33)  is  suggested  when  the  pulse 
is  weak  in  proportion  to  the  heart  sounds.  The  condition 
can  generally  be  recognized  if  its  mode  of  development  has 
been  noticed. 

The  best  remedy  is  a  saline  infusion.  It  may  cause  a 
rapid  fall  in  the  pulse  rate  and  a  marked  improvement  in 
the  pulse.  It  may  be  necessary  to  repeat  the  infusion  after 
some  hours  or  it  may  not  be  required  again. 

DIARRHCEA. 

Severe  diarrhoeas  are  dangerous  and  must  be  checked. 

1.  Examine  stools  to  determine  if  they  contain  undigested 
food.  If  so,  omit  that  kind  of  food  or  reduce  the  amount. 
Curds  from  milk  may  be  found. 

2.  Tincture  of  opium  or  Paregoric  generally  acts  well. 

CONSTIPATION. 

Constipation  is  a  frequent  cause  of  fever  in  convales- 
cence.    Calomel  or  Fl.  Ex.  of  Cascara  Sagrada,  Castor-oil 


Chap.   I,    p.    31,    33. 


81 

or   "  Russian   oil "    (p.   179)    may   be   given   at   this   stage. 
Foecal  impaction  should  be  avoided. 

DISTENSION. 

1.  If  stools  show  curds  reduce  or  omit  milk. 

2.  Turpentine  stupes  *  may  give  relief  and  can  be  used 
p.r.n. 

3.  Rectal  tube  may  be  tried. 

VOMITING. 

Reduction  or  modification  of  diet  is  advisable  for  a  time 
at  least.  Swallowing  small  pieces  of  cracked  ice,  or  a  tea- 
spoonful  of  shaved  ice  with  brandy  may  relieve. 

HEADACHE. 

If  not  relieved  by  an  ice-cap  placed  on  the  forehead,  phe- 
nacetin  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.),  with  caffeine 
citrate  1  gr.  (or  0.065  gm.),  or  some  other  analgesic  may 
be  prescribed. 

COMPLICATIONS. 

I.  HEMORRHAGE  FROM  THE  BOWEL. 

Signs.  First  sign  of  small  hemorrhage  is  blood  in  the 
stool.  First  sign  of  large  hemorrhage  may  be  a  rapid  fall 
in  temperature  and  a  rise  in  the  pulse  rate. 

Treatment.     1.  Omit  nourishment,  water,  and  baths. 

2.  Give  nothing  but  cracked  ice  by  mouth  for  24°. 

3.  Give  morphine  subcutaneously  —  repeat  dose  in  15 
minutes  or  half  an  hour  and  repeat  again  at  half-hour  in- 
tervals until  the  respiration  becomes  slower.  Do  not  let 
the  respiration  fall  below  10  per  minute.  When  it  has 
reached  15  or  less  give  morphine  in  small  dosage,  if  at  all, 
lest  poisoning  result. 

The  object  of  using  morphine  is  to  stop  peristalsis  and  to 
keep  the  patient  quiet  until  the  hemorrhage  has  ceased. 

4.  If  the  patient  be  exsanguinated  raise  the  foot  of  the 


*  See  textbook  on  nursing. 


bed  to  prevent  death  from  syncope  but  do  not  stimulate  un- 
less there  is  imminent  danger,  because  increase  of  blood- 
pressure  may  prolong  the  hemorrhage. 

The  best  circulatory  stimulants  for  this  condition  are  a 
saline  infusion  or  a  direct  transfusion  of  blood. 

5.  For  small  hemorrhages  narcotization  with  morphine 
may  not  be  required. 

6.  Patients  who  are  very  weak  or  emaciated  should  be  fed 
in  spite  of  hemorrhage. 

II.  PERFORATION. 

Treatment. —  Surgical.  Early  diagnosis  and  prompt  oper- 
ation are  essential  to  success.  When  the  condition  of  the 
abdomen  has  been  watched  closely  before  the  appearance 
of  the  symptoms  of  perforation  the  diagnosis  will  be  easier. 
Spontaneous  recovery  is  extremely  rare. 


RHEUMATIC  FEVER. 

Note. —  The  disease,  when  typical,  is  characterized  by  a 
migratory  articular  and  peri-articular  inflammation  with 
pyrexia  and  leucocytosis.  When  untreated  the  inflammation 
generally  lasts  about  six  weeks.  Relapses  are  common  and 
endocarditis  is  frequent.  Pericarditis  or  myocarditis  is  seen 
occasionally. 

There  is  reason  to  believe  that  rheumatic  fever  is  a  form 
of  infectious  arthritis.  Perhaps  most  of  the  cases  are  due 
to  a  specific  organism. 

PRINCIPLES  OF  TREATMENT. 

1.  Rest  in  bed. 

2.  Relieve  pain. 

3.  Dilute  and  eliminate  toxins. 

4.  Prescribe  large  quantities  of  salicylate  and  of  alkali. 

5.  Prevent  recurrence. 

6.  Watch  for  cardiac  complications. 

METHODS. 

1.  Relieve  pain  by  protecting  the  joints  with  cotton  and 
bandages  or  by  splints.     Oil  of  gaultheria  may  be  rubbed  on 


85 


the  skin  before  bandaging  and  fomentations  may  be  useful. 
Occasionally,  when  pain  permits,  a  hot  bath  gives  much 
relief.  If  the  pain  be  severe  and  not  controlled  by  other 
means  use  morphine  hypodermically  until  the  salicylate  has 
had   time   to   act. 

2.  Dilution  and  elimination  of  toxins  can  be  promoted  by 
the  free  administration  of  water.  Three  quarts  or  more 
should  be  ingested  in  twenty-four  hours  unless  the  heart 
be  weak.  Cardiac  complications  may  require  limitation 
of  liquids. 

The  bowels  should  be  kept  clear.  Cathartics  may  be  pre- 
scribed as  needed. 

3.  Food  should  be  nutritious  and  as  abundant  as  can  be 
digested  because  wasting  is  often  rapid  and  anemia  may  de- 
velop. 

4.  Medication.  Sodium  salicylate  (p.  167)  or  some  other 
salicyl  compound  should  be  prescribed  in  large  dosage.  The 
quantity  should  be  proportional  to  the  degree  of  pain  and 
acuteness  of  the  inflammation.  For  severe  cases  10  grs. 
(or  0.65  gm.)  may  be  ordered  every  hour  until  the  patient 
is  relieved  or  toxic.  To  avoid  irritation  of  the  stomach 
every  dose  should  be  given  with  a  full  glass  of  water. 
Large  doses  of  sodium  bicarbonate  seem  to  diminish  the 
toxic  effects  of  salicylates.  Twenty  grains  or  more  of  soda 
may  be  ordered  with  every  dose  of  salicylate.  Enough  soda 
should  be  taken  to  render  the  urine  alkaline. 

Salicin  is  a  good  substitute  for  sodium  salicylate  and 
seems  to  cause  less  gastric  disturbance.  Aspirin,*  or  Oil  of 
wintergreen,  may  be  tried. 

When  symptoms  have  been  relieved  the  dose  of  the  drug 
can  be  reduced.  It  should  be  continued  for  a  month  or 
more  after  the  patient  is  apparently  well. 

When  salicylates  act  well,  in  from  twenty-four  to  forty- 
eight  hours,  a  fall  of  temperature  occurs,  and  with  it  there 
comes  diminution  of  joint  swelling  and  marked  relief  from 
pain. 

The  common  symptoms  of  salicylate  poisoning  are  nausea 
or  vomiting,  tinnitus,  headache  and  occasionally  erythema 


Incompatible  with  alkalis.      (N.N.K,.) 


87 


or  delirium.  When  these  occur  the  drug  must  be  omitted 
until  they  subside.  It  may  then  be  resumed  in  smaller 
dosage  or  in  different  form. 

5.  Recurrence  of  arthritis  is  common  early  or  late. 
Early  recurrence  can  generally  be  avoided  by  keeping  the 

patient  in  bed  for  a  week  after  the  inflammation  has  en- 
tirely subsided  and  by  continuing  the  use  of  sodium  sali- 
cylate, fr.  30  to  40  grs.  (or  2  to  3  gm.)  daily,  for  one  month 
or  more  after  convalescence.  Exercise  should  be  resumed 
gradually. 

Late  recurrence  and  future  cardiac  disease  can  often  be 
prevented  by  eliminating  all  foci  of  suppuration.  Inflam- 
mation of  the  tonsils  or  genital  tract,  sinus  infection  and 
pyorrhoea  alveolaris  should  be  looked  for.  Tonsillectomy 
may  reveal  deep  suppuration  not  demonstrable  externally. 
Tonsillectomy  *  should  be  insisted  on  if  the  tonsils  are  a 
likely  source  for  future  infection.  Pyorrhoea  can  be  bene- 
fited by  rubbing  the  gums  daily  with  a  solution  of  potas- 
sium permanganate  and  by  rinsing  or  sponging  the  mouth 
frequently  with  hydrogen  peroxide  (p.  149). 

6.  Cardiac  complications  may  be  latent  or  severe.  Cir- 
culatory weakness  may  require  limitation  of  liquids. 

The  patient  should  remain  flat  in  bed  for  weeks  or 
months  after  the  disappearance  of  all  signs  of  active  cardiac 
infection,  and  should  avoid  exertion  of  all  kinds  for  several 
months  thereafter  to  give  the  heart  ample  time  to  hyper- 
trophy or  to  adjust  itself  to  the  changes. 

There  is  reason  to  believe  that  salicylates  taken  in  large 
quantity  tend  to  ward  off  endocarditis. 

For  further  information  on  endocarditis  see  Chapter  I, 
page  21. 

LOBAR  PNEUMONIA. 

Notes. —  An  acute  infectious  disease  of  multiple  etiology, 
most  commonly  caused  by  the  pneumococcus.  The  rate  of 
the  pulse  and  respiration  are  indices  of  toxemia. 


Dangerous   while    the    tonsils    are    acutely   inflamed. 


89 


Mortality  commonly  due  to: 

1.  Toxemia  f  (a)   Cardiac  dilatation. 
1  (&)   Vasomotor  paresis. 

less  often  to  f  (a)   Empyema. 

2.  Complications. -<|  (&)   Pericarditis, 
(c)   Endocarditis. 

PRINCIPLES  OF  TREATMENT. 

1.  Secure  good  nursing  and  fresh  air. 

2.  Eliminate  and  dilute  toxins. 

3.  Watch  circulation. 

4.  Stimulate  promptly  when  required. 

5.  Prescribe  drugs   only   for   definite  reasons. 

6.  Take  precaution  to  prevent  accident. 

7.  Diet  suitable  to  case. 

8.  Recognize   complications   promptly. 

METHODS. 

1.  Eliminate  toxins  by  requiring  copious  ingestion  of 
water,  unless  the  heart  be  weak,  and  keep  the  bowels  clear. 
Watch  urinary  output  to  see  that  the  water  is  being  ex- 
creted. 

2.  Out-of-door  treatment  is  likely  to  benefit  robust  pa- 
tients, but  the  old  and  feeble  are  likely  to  do  better  indoors. 
Fresh  air  is,  perhaps,  the  best  stimulant  in  pneumonia. 
Sometimes  it  diminishes  dyspnoea  and  promotes  comfort. 

3.  Note  the  outlines  and  sounds  of  the  heart  and  the  qual- 
ity of  the  pulse  at  every  visit. 

4.  Stimulation  is  indicated  (a)  if  the  quality  of  the  pulse 
be  poor,  (&)  if  it  becomes  irregular  or  (c)  if  the  rate  go 
above  120. 

Irregularity  early  in  the  illness  is  less  apt  to  herald 
danger  than  that  developing  late. 

5.  Morphine  is  indicated  to  relieve  pleuritic  pain  when  a 
tight  swathe  fails  to  do  so.  Sleep  is  very  important  to 
conserve  the  strength  of  the  patient  and  morphine  may 
be  used  to  obtain  it,  especially  in  the  early  stages  of  pneu- 
monia. 

Morphine   is    coiitrain^icated   whenever   bronchial   secre- 


91 


tion  is  profuse,  because  it  checks  expectoration,  and  if  mor- 
phine is  to  be  used  in  the  later  stages  caution  is  necessary. 

6.  Diet  should  consist  of  food  that  requires  no  chewing 
and  that  is  easily  swallowed;    i.e.,  liquids  and  soft  solids. 

The  amount  should  be  gauged  by  the  digestive  power  of 
the  individual,  but  the  course  of  the  disease  is  so  short 
the  nutrition  is  seldom  important. 

7.  Avoid  renal  irritants  and  gas-producing  foods. 
Besides  the  complications  above-mentioned  look  out  for 

a  true  nephritis. 

8.  When  temperature  is  very  high  and  the  heart  doing 
well,  sponge  baths  may  be  used  to  reduce  the  fever. 

9.  Tympanites  may  require  treatment.  An  enema  of  1 
oz.    (or  30  c.c.)    of  glycerine  undiluted  generally  acts  well. 

10.  Dyspnoea  with  cyanosis  can  be  relieved  to  some  ex- 
tent by  inhalation  of  oxygen  passed  through  absolute  alco- 
hol. 

STIMULATION  OF  HEART. 

On  the  third  or  fourth  day,  10  m.  (or  0.6  c.c.)  of  Tr. 
digitalis  may  be  ordered  t.i.d.  It  may,  perhaps,  ward  off 
sudden  dilatation  of  the  heart. 

For  irregularity  or  weakness  caffeine  sodio-salicylate  may 
be  used  subcutaneously,  and  at  the  same  time  digitalis  can 
be  given  by  mouth  for  subsequent  effect,  or  digipuratum 
solution   (p.  159)   can  be  injected  instead  of  caffeine. 

For  acute  cardiac  dilatation  the  following  remedies  may 
be  tried  according  to  circumstances: 

Subcutaneously: 

1.  Digipuratum-solution. 

2.  Camphor   in   oil:    3    grs.    (or   0.2   gm.).     It   should   be 

specially  prepared  for  subcut.  use. 

3.  Caffeine  sodio-salicylate:   3  grs.   (or  0.2  gm.).     It  may 

cause  irritability  or  wakefulness. 

4.  Alcohol  or  ether:    1  drach.    (or  4  c.c). 
Intravenously  Digipuratum-solution   or   Strophanthin    (p. 

159)    may  be  given.     The  latter  is  dangerous. 
By  mouth: 

1.  Brandy,  fr.  *  to  1  oz.   (or  15  to  30  c.c). 

2.  Aromatic  spirits  of  ammonia,  1  drach.   (or  4  c.c). 


93 


Venesection  may  do  good  if  there  is  cyanosis  with  much 
engorgement  of  the  right  ventricle. 

Acute  pulmonary  edema  yields  occasionally  to  a  large 
dose  of  atropine  Yqq  gr.  (or  0.001  gm.)  given  subcutane- 
ously. 

Vasomotor  paresis.  The  momentary  application  of  cold 
in  the  form  of  an  ice-bag  to  the  abdomen  may  do  good  by 
causing  reflex  vascular  contraction.  Salt  solution  subpec- 
torally  or  intravenously  may  be  beneficial.  If  improvement 
results  follow  it  up  with  caffeine. 

DELIRIUM:  TREATMENT. 

Active  delirium  may  be  ameliorated  by  morphine  (see 
sect.  5,  p.  89),  by  hypnotics,  or  sometimes  by  hyoscine  hydro- 
bromate  *  used  subcut.  Alcohol  internally  may  be  of  serv- 
ice for  delirium  with  exhaustion. 

Delirium,  even  when  slight  may  be  dangerous.  When 
the  nurse  leaves  the  room  even  for  a  moment  some  one 
should  take  her  place  lest  the  patient  jump  from  the  win- 
dow.    No  razor  or  weapon  of  any  kind  should  be  left  about. 

BRONCHO-PNEUMONIA. 

Treatment  is  essentially  the  same  as  for  lobar  pneumonia 
except  that  the  disease  generally  runs  a  milder,  but  longer 
course.     Nutrition,  therefore,  is  more  important. 

Bronchitis  is  often  associated  with  broncho-pneumonia 
and,  when  this  is  the  case,  expectorants  may  be  of  service 
during  convalescence. 

ACUTE  INFLAMMATION  OF  THE  UPPER 
RESPIRATORY  TRACT. 

Etiology:  infectious  in  most  instances.  The  pneumococ- 
cus,  staphylococcus,  influenza  bacillus,  diphtheria  bacillus, 
micrococcus  catarrhalis  or  other  bacteria  may  be  causative. 
Among  predisposing  factors  lowered  physical  resistance  and 
exposure  to  cold  are  important. 


Scopolamine  is  chemically  the  same  as  hyoscine.      (U.S.D.) 


95 


Course  of  Disease.  Inflammation  generally  begins  in  the 
nasopharynx  (pharyngitis).  It  usually  extends  within  a 
few  days  to  the  nasal  mucous  membrane  (coryza)  and  often 
to  the  tonsils  (tonsillitis)  or  larynx  (laryngitis).  The  se- 
verity and  extent  of  the  inflammation  depends  chiefly  on 
the  kind  and  virulence  of  the  infecting  organism  and  on 
the  resistance  of  the  patient. 

Complications  and  Sequelae. 

1.  Bronchitis.  8.  Bronchiectasis. 

2.  Otitis   media.  9.  Septicgemia. 

3.  Peritonsillar    abscess.  10.  Meningitis. 

4.  Lobar      or      broncho-  11.  Peritonitis. 

pneumonia.  12.  Inflammation    of    the 

5.  Arthritis.  antrum,  frontal, 

6.  Endocarditis.  ethmoidal    or    sphe- 

7.  Glomerulo-nephritis.  noidal  sinuses. 

Diagnosis.  Exclude  whooping-cough,  scarlet  fever,  meas- 
les and  diphtheria.  The  diagnosis  of  diphtheria,  in  some 
cases,  can  be  made  by  culture  only.  Therefore  the  safest 
plan  is  to  take  a  culture  in  every  case  of  inflammation  of 
the  throat  and  to  repeat  it,  if  the  report  be  negative  but 
the  signs  suggestive  of  diphtheria. 

PROPHYLAXIS. 

1.  If  there  is  a  reasonable  probability  that  the  symptoms 
are  due  to  diphtheria  or  to  one  of  exanthemata  isolate  the 
patient  provisionally. 

2.  If  the  clinical  evidence  points  to  diphtheria  adminis- 
ter antitoxin  (p.  151)  to  the  patient  without  waiting  for  the 
culture;    or  even  if  the  first  culture  be  negative. 

Prophylactic  inoculation  of  all  persons  exposed  to  diph- 
theria should  be  insisted  on. 

3.  Patients  having  infections  of  the  respiratory  tracts 
should  cover  the  mouth  on  coughing  or  sneezing. 

4.  Good  ventilation  of  rooms  occupied  by  the  patient  re- 
duces risk  of  contagion. 

TREATMENT  APPLICABLE  IN  GENERAL. 

1.  Keep  the  patient  in  a  warm,  but  well-ventilated  room 
at  a  uniform  temperature. 


97 

2.  Promote  rest  and  sleep,  using  sedatives  or  hypnotics 
when  needed. 

3.  Move  bowels,  at  outset,  by  enema  or  cathartic  unless 
they  have  been  acting  freely. 

4.  Allay  unproductive  or  irritating  cough. 

5.  Avoid  local  irritation  by  tobacco  or  concentrated 
liquor. 

6.  Cleanse  mucous  membrane  frequently,  and  soothe  in- 
flammation by  means  of  a  non-irritating  gargle.  Warm 
water,  with  or  without  salt  or  sodium  bicarbonate  in  it,  or 
Liquor  antisepticus  alkalinus  may  be  used  diluted  with 
3  parts  of  warm  water. 

7.  Antipyretics,  e.g.,  phenacetin  fr.  5  to  10  grs.  (or  0.3 
to  0.65  gm.),  with  caffeine  citrate  1  gr.  (or  0.065  gm.),  or 
salicyl  preparations  (p.  167),  may  alleviate  discomfort  espe- 
cially if  there  be  fever,  malaise  or  pain. 

8.  Food  should  be  readily  digestible  and  easy  to  swallow. 
Abortive  Treatment.     This  can  be  effective  in  the  early 

stages  only,   and   seldom  even  then.     The   following   meas- 
ures may  be  tried. 

1.  Cleansing,  non-irritating  gargle. 

2.  Hot  bath  before  retiring,  or 

3.  Hot  drink  on  retiring  to  produce  sweating. 

4.  Early  to  bed,  and  hypnotic  unless  sleep  comes  quickly. 

5.  Catharsis  by  calomel  or  saline. 

6.  The  patient  should  dress  in  a  warm  room  and  avoid 
cold  bathing  on  the  following  morning. 

METHODS  OF  TREATMENT. 

ACUTE  PHARYNGITIS. 

1.  Cleansing  gargle  every  four  hours. 

2.  Oil  spray  *  after  gargle  to  protect  and  soothe  mucous 
membrane. 

3.  Check  cough  with  lozenges  or  sedatives. 


*  Petrolatum  liquidum  will  serve.  Menthol  5  grs.  (or  0.3  gm.)  or 
Eucalyptol  5  min.  (or  0.3  c.c.)  or  both,  can  be  added  per  oz.  (or  30 
c.c.)    of  liquid  petrolatum.      The   De  Vilbiss   atomizer  is  good. 


99 


CORYZA. 

Keep  the  nose  as  free  as  possible  from  secretion. 

Irrigation  of  tlie  nose  with  an  alkaline  solution  often 
gives  much  relief,  but  some  physicians  believe  that  this 
practice  may  lead  to  inflammation-  of  the  frontal  sinus  or 
middle  ear.  An  oil  spray  (p.  97)  may  be  used  to  free  the 
nasal  passages. 

If  the  secretion  be  profuse  and  watery,  its  quantity  can 
be  diminished  by  using  ^^^  gr.  (or  0.00032  gm.)  of  atro- 
pine sulphate  and  repeating  it  in  fr.  4  to  6  hours  s.o.s. 
Atropine  is  contraindicated  when  secretion  is  viscid  or  te- 
nacious. Excessive  dosage  causes  dryness  of  the  throat, 
increases  discomfort,  and  may  cause  severe  poisoning. 

Atropine  can  be  used  in  the  form  of  Tr.  of  belladonna 
leaves;   dose  from  10  to  30  min.   (or  0.6  to  2  c.c). 

ACUTE  TONSILLITIS. 

1.  Take  a  culture. 

2.  Whereas  the  constitutional  symptoms  are  apt  to  be 
severe  it  is  generally  advisable  to  keep  the  patient  in  bed. 

3.  Prescribe  cleansing  gargle  to  be  used  every  four  hours. 
The  tonsils  may  be  painted  daily  with  argyrol,*  fr.  10  to 
20%    in    watery    solution. 

4.  An  oil-spray  (p.  97),  used  after  gargling,  may  give 
some  relief. 

5.  An  ice-bag  collar  may  help  much  to  relieve  pain  in  the 
throat. 

6.  The  diet  must  be  easy  to  swallow.  Cold  drinks  may 
be  grateful. 

7.  Occasional  doses  of  phenacetin  or  of  salicylate  (p. 
167)   may  be  beneficial  for  fever,  malaise  or  pain. 

8.  Opiates  or  hypnotics  are  indicated  sometimes. 

9.  Salicylate  (p.  167)  in  large  doses  acts  well  in  some 
cases  of  tonsillitis  having  slight  articular  symptoms  due 
probably  to  streptococcus  infection. 

10.  Note  at  first  visit  the  size,  position  and  sounds  of  the 
heart,   and   the    presence   or   absence   of   murmurs.     Watch 

*  u.  s.  t. 


101 

for  any  change  and  before  discliarging  the  patient,  deter- 
mine whether  the  heart  or  the  kidneys  have  suffered. 

ACUTE  LARYNGITIS. 

1.  Scarification,  intubation  or  even  tracheotomy  may  be 
required  for  edema. 

2.  Steam,  plain  or  medicated,  ordinarily  gives  relief.  It 
should  be  used  every  few  hours  or  as  desired.  The  steam 
can  be  inhaled  from  the  mouth  or  from  a  pitcher  contain- 
ing boiling  water.  To  the  water  may  be  added  1  drach. 
(or  4  c.c.)  of  compound  tincture  of  benzoin.  A  steam 
atomizer  is  better  still.  The  "  Acme  "  is  good,  and  it  can 
be  used  to  spray  oil  and  steam  together.  For  very  sensi- 
tive throats  the  steam  and  oil  may  act  better  without  other 
ingredients,  but  Menthol  5  grs.  (or  0.3  gm.),  or  Eucalyptol 
5  min,  (or  0.3  c.c),  or  both  can  be  added  per  oz.  (or  30 
c.c.)    of  Liquid  petrolatum. 

Excessive  dryness  of  the  air  of  the  room  is  harmful. 
It  can  be  mitigated  by  allowing  steam  to  escape  constantly 
from  a  kettle  or  chafing  dish, 

3.  Cough  must  be  checked  and  talking  minimized. 

4.  Smoking  is  especially  harmful  as  a  rule. 

ACUTE  TRACHEITIS. 

Treatment   as    for   laryngitis   may   suffice. 

A  flaxseed  or  mustard  poultice  *  for  the  upper  chest  or 
steam  inhalation  may  help  to  relieve  substernal  distress. 
Mustard  should  be  avoided  if  resulting  pigmentation  would 
contraindicate  its  use.  "  Gomenol  jujubes  "  t  taken  every 
3  to  6  hours  may  relieve. 

BRONCHITIS. 

ETIOLOGY. 

Acute  bronchitis  commonly  follows  infections  of  the 
upper   respiratory    tract   and    especially    infections    by   the 


*  See  textbook  on  nursing. 

fA  preparation   of   oleum   cajuputi    (U.S.). 


lOJ 


pneumococcus  or  influenza  bacillus.  It  occurs  sympto- 
matically  in  some  infectious  diseases,  e.g.,  typhoid  and 
measles. 

Chronic  bronchitis  is  often  associated,  in  old  or  middle- 
aged  persons,  with  slight  cardiac  insufficiency  or  with 
emphysema.     Rarely,  gout  is  a  factor. 

DIAGNOSIS. 

Acute  or  chronic  bronchitis  may  be  simulated  by  tuber- 
culosis and,  therefore,  sputum  examination  is  imperative. 
Many  cases  of  bronchiectasis  following  influenza  are 
wrongly  diagnosed  as  bronchitis  or  as  phthisis. 

ACUTE  BRONCHITIS:  TREATMENT. 

1.  The  patient  should  keep  warm  and  avoid  change  of 
temperature  by  staying  indoors. 

2.  If  there  is  fever,  bed  may  be  advisable  or  necessary. 

3.  Bronchial  secretion  must  be  expectorated,  but  unpro- 
ductive cough  should  not  be  allowed  to  fatigue  the  patient 
or  to  prevent  sleep. 

If  the  cough  comes  from  pharyngeal  irritation,  lozenges 
may  suffice  to  check  it;  if  from  the  larynx  or  trachea, 
steam  inhalations  (p.  101)  may  be  serviceable.  If  neces- 
sary for  relief  of  cough  codeine  sulphate  1  gr.  (or  0.016 
gm.)  or  heroine  hydrochloride  *  j\  gr.  (or  0.005  gm.)  may 
be  prescribed  for  use  in  the  afternoon  or  at  night.  Morn- 
ing cough  is  generally  needed  to  clear  the  lungs.  It  can 
be  promoted  by  a  hot  drink. 

4.  Substernal  distress  or  pain,  see  tracheitis,  p.  101. 

5.  Expectorants  are  contraindicated  during  the  acute 
stage  of  bronchitis  because  they  irritate  the  inflamed  mu- 
cous membrane.  They  may  be  used  during  convalescence, 
at  which  time  the  expectoration  is  often  tenacious  and  diffi- 
cult to  raise. 

6.  Several  weeks  are  generally  required  for  complete  re- 
covery, but  when  the  patient  feels  well  he  may  be  allowed 


*  The   hydrochloride   of   the   diacetic    ester   of   morphine    (U.S.D.)    not 
official.      ''Heroin"    is   a   name   bearing   U.S.    and    (N.N.R.). 


105 


to  resume  his  occupation.  Smoking  and  cold  bathing 
should  be  resumed  cautiously  and  unnecessary  exposure 
should  be  avoided  as  long  as  expectoration  persists. 

CHRONIC  BRONCHITIS:  TREATMENT. 

1.  Expectorants  are  generally  beneficial,  particularly  po- 
tassium iodide  in  the  dose  of  fr.  5  to  10  grs.  (or  0.3  to 
0.6  gm.),  t.i.d. 

2.  When  there  is  any  sign  of  cardiac  insufficiency,  ap- 
propriate stimulants  are  indicated.  For  slight  insufficiency 
the  Compound  Squill  Pill  may  act  well  both  as  a  heart 
stimulant  and  as  an  expectorant.  The  usual  dose  is  from 
6  to  9  pills  daily.  They  should  be  freshly  prepared.  Syste- 
matic cardiac  treatment  may  be  required. 

3.  An  equable  and  warm  climate  may  promote  comfort, 
especially  for  elderly  persons. 

4.  If  the  presence  of  bronchiectasis  be  suspected  treat 
the  case  as  one  of  bronchiectasis   (p.  107). 

5.  Acute  exacerbations  of  chronic  bronchitis  may  be 
treated  much  as  is  acute  bronchitis,  but  severe  symptoms 
generally  indicate  that  some  form  of  pneumonia  has  de- 
veloped, and  treatment  should  be  regulated  accordingly 
(p.  89). 

6.  Codeine  sulphate  or  heroine  hydrochloride  should  not 
be  used  consecutively  over  long  periods  on  account  of  the 
danger  of  forming  a  habit. 

7.  The  bronchitis  of  overfed  patients  is  often  benefited 
by  depletion.     Exclude  gout  as  a  factor. 

Note. —  Much  improvement  may  be  hoped  for  but  cure  is 
hardly  to  be  expected  in  chronic  bronchitis. 

BRONCHIECTASIS. 

Note. —  The  disease  is  chronic,  lasting  for  thirty  years, 
more  or  less.  The  patient  may  be  subject  to  recurring  at- 
tacks of  broncho-pneumonia,  or  of  hemoptysis.  Many  pa- 
tients have  emphysema  or  asthma.*     The  condition  is  often 


*  Empyema,    abscess,    arthralgia,    or   pneumothorax   occur    in   rare    in- 
stances. 


107 


diagnosed  wrongly  as  bronchitis  or  tuberculosis.  Many 
cases  are  traceable  to  influenza.  The  sputum,  typically,  is 
abundant,  purulent,  greenish,  nummular,  can  be  raised  at 
will  by  coughing,  and  often  contains  abundant  influenza 
bacilli  as  well  as  various  other  organisms.  Repeated  ex- 
aminations may  be  necessary  to  demonstrate  the  influenza 
bacilli.  The  cavities  may  be  localized  in  one  lobe  or  dis- 
seminated throughout  both  lungs.  Nutrition  is  generally 
good.  As  the  physical  examination  may  show  only  a  few 
rales,  the  diagnosis  must  rest  on  the  history,  the  character, 
and  the  amount  of  the  sputum. 

TREATMENT. 

No  method  yet  devised  offers  hope  of  cure. 
Efforts  must  be  directed  to  relieving  the  patient  as  far 
as  possible  from  unpleasant  symptoms. 

1.  Teach  the  patient  to  drain  his  cavities  on  rising  in  the 
morning,  and,  if  necessary,  once  or  twice  later  in  the  day. 
This  can  be  facilitated  by  taking  a  drink  of  hot  water,  tea 
or  coffee  at  such  times.  Potassium  iodide  fr.  5  to  10  grs. 
(or  0.3  to  0.65  gm.)  or  other  expectorants  may  be  used  if 
the  secretion  be  too  viscid  to  come  up  readily. 

2.  Avoid  sedatives  because  they  check  free  expectora- 
tion. The  material  then  decomposes  in  the  cavities  and 
gives  a  foul  odor  to  the  breath  and  to  the  sputum. 

3.  In  extreme  instances  of  retained  secretion  the  condi- 
tion with  its  dyspnoea  and  cyanosis  may  simulate  bronchial 
asthma.  A  differential  diagnosis  can  be  made  from  history 
and  sputum.  An  emetic  will  give  immediate  relief  by 
clearing  the  lungs. 

4.  Most  of  these  patients  are  better  in  warm  weather.  A 
uniformly  mild  climate  may  relieve  but  cannot  cure. 

5.  Sputum  must  not  be  swallowed  because  diarrhcea  may 
result. 

6.  Foul-smelling  sputum  means  inefficient  drainage  of 
cavities.  The  odor  can  be  ameliorated  by  the  use  of  3  min. 
(or  0.2  c.c.)  of  Eucalyptol  on  a  lump  of  sugar  several  times 
daily. 

7.  When  the  disease  is  localized  in  one  lobe  of  the  lung 
the  chance  of  relief  by  surgical  means  may  be  considered. 


CHAPTER  lY. 


GASTRIC  AND  DUODENAL  ULCER. 

INDICATIONS  FOR  MEDICAL  TREATMENT. 

1.  Recent  ulcers. 

2.  Chronic  ulcers  with  mild  sj^mptoms. 

3.  Chronic  ulcers  which  have  not  had  satisfactory  med- 
ical treatment. 

4.  Ulcers  for  which  surgical  treatment  is  too  dangerous 
or  has  been  refused. 

5.  As  a  preparation  for  operation. 

The  prognosis  under  medical  treatment  is  better  the 
more  recent  the  ulcer. 

PRINCIPLES  OF  TREATMENT. 

The  principles  and  methods  are  essentially  the  same 
whether  the  ulcer  is  in  the  stomach  or  in  the  duodenum. 

1.  Prolonged  rest  for  the  patient  and  for  the  digestive 
tract. 

2.  Avoidance  of  food  mechanically  or  chemically  irri- 
tating. 

3.  Reduction  of  gastric  secretion  to  the  minimum. 

4.  Good  care  of  teeth. 

METHODS. 

A.  Rest  in  bed  for  a  month  is  essential. 

B.  Diet  should  consist  chiefly  of  soft  carbohydrates, 
fats,  milk,  and  eggs.     Feeding  should  be  frequent. 

Treatment  may  be  begun  by  starvation  for  several  days, 
with  or  without  nutritive  enemata.  If  the  patient  be 
strong  and  if  he  absorbs  nutritives  well  they  may  be  used 
during  the  first  week  without  any  mouth  feeding.     During 

109 


Ill 

ttie  period  of  starvation  three  pints  of  salt  solution  should 
be  given  daily  by  rectum.  Cracked  ice  may  be  sucked  to 
allay  thirst. 

Begin  feeding  with  small  quantities  of  milk  (see  Vomit- 
ing, p.  121).  Later,  bread,  or  crackers  and  milk,  milk  toast, 
strained  cereals  with  cream  and  sugar,  rice,  custard,  blanc- 
mange, junket,  simple  ice  cream,  mashed  or  baked  potato 
with  cream  or  butter,  eggnog,  raw  or  soft  boiled  or  dropped 
egg,  purees,  soft  fruits,  etc.,  can  be  added  later  to  the 
dietary  until  the  patient  is  taking  ample  nourishment. 

The  nutritive  value  of  liquids  can  be  much  increased 
by  adding  to  them  sugar  of  milk,  fr.  i  to  1  oz.  in  4  oz.  (or 
fr.  15  to  30  gm.  in  120  c.c.)  of  liquid.  Cream  may  be  added 
to  milk,  and  butter  should  be  used  freely. 

Irritating  foods,  e.g.,  coarse  vegetables,  condiments,  acids, 
and  particularly  alcohol  must  be  avoided. 

Hot  drinks  and  meat  broths,  as  a  rule,  should  not  be 
taken. 

Proteid  foods,  in  the  opinion  of  the  writer,  are  to  be 
avoided,  as  a  rule,  except  in  the  form  of  milk  or  eggs. 

C.  Modification  of  diet  is  required  for  patients  that  are 
emaciated,  or  feeble  and  anemic.  For  them  starvation  may 
be  harmful,  and  it  may  be  wise  to  begin  feeding  by  mouth 
soon  after  the  hemorrhage  has  stopped,  and  quickly  to  in- 
crease the  amount  of  food  ingested  in  order  to  accelerate 
healing  by  improved  nutrition.  The  experience  of  the  pa- 
tient requires  consideration. 

In  marked  contrast  to  those  expressed  above  are  the 
views  held  by  some  physicians  who  advocate  a  diet  con- 
sisting chiefly  of  proteid.  Their  aim  is  to  neutralize  the 
acid  as  fast  as  it  is  formed  by  means  of  proteid.  Frequent 
feedings  are  recommended  with  the  same  object. 

Lenhartz  is  one  of  these,  and  his  method  may  be  pre- 
ferred for  some  cases.     His  diet  schedule  follows,  p.  117. 

D.  Reduction  of  gastric  secretion  *  may  be  favored  by 
starvation,  by  a  diet  low  in  proteid,  by  the  avoidance  of 
salt  and  by  the  administration  of  a  tablespoonful  of  olive 
oil  several  times  daily. 


*  Small   doses   of  atropine   are  recommended  by   some  physicians, 


113 


E.     Medication: 

1.  Sodium  bicarbonate  stiould  be  prescribed  freely  for 
relief  of  pain  or  distress  in  the  dose  of  fr.  ^  to  1  teaspoon- 
fiil,  or  more  if  required,  in  a  glass  of  water.  A  hot  water 
bag  may  relieve. 

2.  After  feeding  has  been  begun  bismuth  subnitrate 
should  be  given  three  times  daily  in  teaspoonful  doses 
before  meals  with  the  hope  of  benefit  by  coating  the  ulcer 
mechanically.  Bismuth  is  not  constipating  in  this  dose. 
It  is  important  that  the  drug  should  be  pure.* 

3.  The  bowels  should  be  kept  free  by  enema  or  by  mild 
cathartics.  Milk  of  magnesia  acts  well  as  a  cathartic  and 
is  also  an  antacid. 

D.     Convalescence: 

1.  General  hygienic  measures  including  attention  to  the 
bowels  are   important. 

2.  Work  should  be  resumed  gradually  and  much  fatigue, 
psychical  more  than  physical,  should  be  avoided. 

3.  Rest,  lying  down,  for  from  ^  to  1  hour  after  meals  is 
of  great  benefit. 

4.  Food  should  be  taken  in  the  middle  of  the  morning, 
the  middle  of  the  afternoon  and  at  bedtime  in  addition  to 
regular  meals. 

5.  The  more  strictly  the  diet  and  regimen  can  be  followed 
the  greater  the  chance  of  success  but  it  is  better  to  en- 
large the  dietary  than  to  undernourish  the  patient  because 
good  nutrition  favors  healing  of  the  ulcer.  The  treatment 
should  be  followed  as  strictly  as  practicable  for  from  six 
months  to  a  year. 

COMPLICATIONS:  TREATMENT. 

A.  Hemorrhages,  when  small,  require  no  special  treat- 
ment. 

When  a  severe  hemorrhage  occurs  the  patient  should  lie 
as  still  as  possible  and  morphine  should  be  given  subcu- 
taneously  in  dosage  sufficient  to  bring  the  patient  well 
under  its  influence  and  to  inhibit  peristalsis  (p.  81).  Fur- 
ther medication  is  not  likely  to  do  good. 


*  Squibb's  is  good  for  this  purpose. 


115 


An  ice-bag  may  be  placed  over  the  stomach. 

Stimulation  of  the  circulation  by  salt  solution,  by  trans- 
fusion of  blood,  or  by  drugs  should  be  withheld  unless  de- 
manded by  immediate  danger,  because  raising  the  blood- 
pressure  may  prolong  the  hemorrhage. 

If  syncope  be  feared  after  hemorrhage  it  may  be  advis- 
able to  raise  the  foot  of  the  bed. 

Operation  is  seldom  indicated  during  hemorrhage  be- 
cause most  hemorrhages  stop  spontaneously,  and  because 
when  the  patient  has  become  exsanguinated  operation  is 
dangerous. 

Repeated  hemorrhage  is  an  indication  for  operation  after 
the  patient  has  recovered  sufficiently  from  the  resulting 
anemia.  Transfusion  may  be  advised  to  hasten  recovery 
or  to  prepare  for  subsequent  operation. 

B.  Perforation  may  be  acute  or  subacute.  It  may  lead 
to  general  peritonitis,  to  abscess,  or  to  adhesions  causing 
persistent,  severe  symptoms. 

The  acute  perforations  and  those  with  abscess  formation 
should  receive  prompt  surgical  treatment.  Early  diagnosis 
is  very  important. 

G.  Pyloric  obstruction,  when  severe,  requires  operation. 
Incomplete  obstruction  with  gastric  dilatation  can  often 
be  relieved  temporarily  and  sometimes  for  long  periods  by 
rest  in  bed,  lavage  daily  before  breakfast,  and  a  soft  diet 
with  limited  liquids.  Under  such  treatment  the  dilated 
stomach  may  contract  and  acute  inflammation  at  the  py- 
lorus may  subside. 

This  is  an  excellent  preparation  for  operation.  Opera- 
tion should  be  urged  early  for  pyloric  obstruction  because 
when  the  symptoms  have  become  imperative  the  weakened 
condition  of  the  patient  adds  greatly  to  the  risk. 

D.  Persistent  severe  symptoms  which  do  not  yield  to 
medical  treatment  demand  that  operation  be  seriously  con- 
sidered. 


117 


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119 


ACUTE  GASTRITIS  AND  GASTRO- 
ENTERITIS. 

Pathology:  Acute  irritation,  probably  with  hypersemia, 
and  possibly  with,  inflammation  of  the  mucous  membrane 
of  the  stomach,  of  the  intestines  or  of  both. 

Etiology:  1.  Ingestion  of  food  unwholesome  either  in  it- 
self or  for  the  individual. 

2.  Excess  of  food. 

3.  Excess  of  alcohol  or  other  beverage. 

Diagnosis  of  gastritis  with  vomiting  is  made  by  history 
and  by  exclusion. 

Do  not  overlook  the  following  diseases  which  may  cause 
vomiting: 

1.  Acute     infectious     dis-  7.  Acute   drug  poisoning. 

eases    including    ma-  8.  Brain    tumor. 

laria.  9.  Tabes    dorsalis. 

2.  Nephritis.  10.  Angina  pectoris. 

3.  Pregnancy.  11.  Chronic    gastric    or    in- 

4.  Migraine.  testinal  diseases. 

5.  Lead  colic.  12.  Acute     surgical     condi- 

6.  Hysteria.  tions,   e.g.,   appendici- 

tis,   cholecystitis,    re- 
nal colic,  etc. 

PRINCIPLES  OF  TREATMENT. 

1.  Rest  and  warmth  for  patient. 

2.  Removal  of  cause  of  symptoms, 

3.  Rest  for  digestive  tract. 

4.  Symptomatic  treatment. 

METHODS. 

Methods  must  be  chosen  with  regard  to  the  cause,  se- 
verity and  nature  of  symptoms. 

1.  Rest  and  Warmth.  The  patient  should  lie  down  and 
should  be  warmly  covered  or  should  remain  in  bed.  Hot- 
water  bags  may  be  useful  for  cold  extremities  or  for  ab- 
dominal distress  or  pain.  Rest  and  warmth  diminish 
metabolic  waste  and  promote  recuperation. 

2.  Removal   of  Cause.     If  the  distress  is  gastric,  and   if 


121 


the  stomach  has  not  been  freely  emptied,  emesis  may  be 
induced  by  administering  quantities  of  warm  water  or  by 
means  of  a  teaspoonful  of  mustard-powder  mixed  in  a  cup 
of  warm  water. 

If  symptoms  come  from  the  intestine  the  bowel  should 
be  evacuated  unless  profuse  diarrhoea  has  cleared  it  thor- 
oughly. A  saline  cathartic,  or  calomel  followed  by  a  sa- 
line cathartic,  may  be  of  service  if  the  stomach  can  retain 
it.  An  enema  may  be  given  at  any  time  for  prompt  effect 
or  if  cathartics  cannot  be  retained.  Both  emesis  and  ca- 
tharsis are  necessary  for  some  severe  cases. 

3.  Rest  for  Digestive  Tract.  Well-nourished  patients 
generally  do  best  without  food  of  any  kind  for  from  12 
to  24  hours.  Plain  water  or  mineral  water  may  be  al- 
lowed in  small  quantities  at  short  intervals. 

When  beginning  to  feed  it  is  wise  to  use  liquids,  such  as 
beef  tea,  chicken  broth,  hot  milk  or  orange  juice,  a  few 
ounces  every  two  hours.  The  nourishment  should  be  in- 
creased in  amount  and  in  kind  more  or  less  rapidly  ac- 
cording to  the  physician's  estimate  of  the  patient's  diges- 
tive capacity.  Hunger  and  a  clean  tongue  generally  indi- 
cate that  considerable  quantities  of  food  can  be  assimi- 
lated; whereas  a  coated  tongue  and  disgust  for  food  mean 
the  reverse. 

4.  Symptomatic   Treatment. 

(a)  Nausea  generally  yields  to  rest  and  abstinence  from 
food.     Emesis  is  advisable  for  some  cases. 

(&)  Vomiting  usually  stops  spontaneously  when  the 
stomach  has  been  emptied.  If  it  does  not  yield  to  rest  and 
abstinence  from  food  it  may  be  checked  sometimes  by  a 
teaspoonful  of  shaved  ice  with  brandy,  by  a  drop  of  Tr. 
of  iodine  in  a  teaspoonful  of  water,  by  i  gr.  (or  0.016  gm.) 
of  cocaine  hydrochloride  dissolved  in  a  teaspoonful  of 
water,  by  ^  gr.  (or  0.008  gm.)  of  morphine  sulphate  ab- 
sorbed from  the  mouth,  by  other  drugs,  or  by  gastric  lav- 
age. Food  should  be  withheld  entirely  for  from  about  3 
to  12  hours  after  vomiting  has  ceased.  Water  should  be 
allowed  during  this  period  in  very  small  amounts  if  at  all. 
Cracked  ice  may  be  sucked  for  thirst. 

When   gastric   disturbance   lasts   over   a   period    of   days, 


123 


salt  solution  must  be  administered  in  the  form  of  enemata, 
by  rectal  seepage  or  by  hypodermoclysis.  Three  pints  in 
24  hours  is  enough.  These  measures  and  rectal  feeding 
are  very  rarely  needed  in  acute  gastritis. 

Feeding  should  be  resumed  cautiously,  using  milk  di- 
luted with  mineral-water,  lime-water,  or  carbonated  water; 
or  orange  juice,  or  broth  in  teaspoonfuls  every  half  hour. 
The  quantity  of  nourishment  should  be  increased  and  the 
intervals  between  feedings  lengthened  gradually. 

(c)  Diarrhoea  should  not  be  checked  until  all  old  faecal 
matter  has  been  discharged.  If  the  diarrhoea  persists  in 
a  mild  form  a  few  doses  of  about  15  grs.  (or  1  gm.)  of 
bismuth  subnitrate  may  suffice  to  stop  it.  When  diarrhoea 
is  severe  opiates  are  often  required.  A  teaspoonful  of 
paregoric  may  be  prescribed  after  each  loose  movement. 
Morphine  may  be  required  subcutaneously.  For  other 
medicaments  see  p.  127. 

(d)  Colic  can  be  checked,  when  slight,  by  the  applica- 
tion of  heat  to  the  abdomen  and  by  rest  and  abstinence 
from  food. 

Paregoric  or  other  preparations  of  opium  or  morphine 
may  be  used  for  severe  pain  but  they  are  contraindicated 
in  full  dosage  until  the  intestinal  tract  has  been  cleared, 
and  also  when  conditions  which  may  require  surgical  in- 
terference cannot  be  ruled  out. 


SIMPLE  DIARRHCEA. 

DIAGNOSIS. 

Do  not  overlook  the  following  diseases  which  may  cause 
diarrhoea. 

1.  Dysentery,  bacillary  or  amoebic. 

2.  Other  infectious  diseases,  e.g.,  typhoid. 

3.  Nephritis  with  colitis. 

4.  Carcinoma  of  lower  bowel. 

5.  Faecal  impaction  with  intermittent  diarrhoea. 

6.  Rectal  diseases  with  tenesmus. 

7.  Mucous  colitis. 


125 

8.  Reflex  or  nervous  diarrhoea,  e.g.,  due  to  chill,  exophthal- 

mic goitre,  or  perhaps  to  anxiety. 

9.  Habitual  excess  in  eating  and   insufficient  exercise. 

10.  Irritating   ingesta   or   imperfectly    digested    food. 

PRINCIPLES  OF  TREATMENT. 

Suit  methods  to  severity,  duration  and  persistence  of 
symptoms : 

(a)   Remove   irritant,  usually   imperfectly  digested   food. 

(&)   By  means  of  a  suitable  diet  avoid  further  irritation. 

(c)   Limit  peristalsis. 

{d)  When  there  is  toxemia,  dilution  and  elimination  of 
toxins  is  important   (p.  69). 

METHODS. 

A.  To  Remove  Irritant.  Unless  bowel  has  been  thor- 
oughly evacuated  prescribe  a  purge  which  will  act  quickly 
and  ascertain  that  this  result  has  been  obtained  before  pro- 
ceeding to  other  kinds  of  medication. 

A  saline,  or  castor  oil,  may  be  used.  If  these  are  vom- 
ited an  enema  may  do  good.  It  may  be  advisable  to  induce 
emesis    (p.  121).     Calomel  generally  acts  well   (p.  175). 

B.  The  Diet  should  be  non-irritating;  should  leave  lit- 
tle residue;    and,  preferably,   should  be  digested  high  up. 

Eggs,  broths  and  lean  meats  are  well  digested  as  a  rule. 

Starches  containing  little  cellulose  may  be  preferred  oc- 
casionally. 

Fats,  fruits  and  coarse  vegetables  in  general  are  tb  be 
avoided. 

Liquids  should  be  bland  and  not  cold. 

C     To   limit  peristalsis,     (a)   Rest,  preferably  in  bed. 

(ft)  Restriction  of  ingesta.  Meals  should  be  small  and 
frequent.  In  severe  conditions  of  short  duration  food  and 
liquids  may  be  forbidden  entirely  for  a  time.  The  length 
of  time  depends  on  the  state  of  nutrition  and  tolerance  of 
the  patient. 

(c)  Warmth,  externally  and  internally,  i.e.,  a  warm 
room,  avoidance  of  changes  of  temperature,  a  hot-water 
bag  on  abdomen  and  hot  drinks. 


127 


MEDICATION. 

(a)  Astringents.  Bismuth  subnitrate,  fr.  10  to  20  grs. 
(or  0.65  to  1.3  gm.)    every  2  to  8  hours. 

Acidum  tannicum  (U.  S.),  boiled  green  tea,  red  wine,  or 
Tannalbin  *  may  be  tried. 

(&)  Sedatives.  Opiates  are  best,  e.g.  Tr.  opii  camphor- 
ata  (U.  S.)  "Paregoric,"  or  Tr.  opii  deodorati  (U.  S.),  or 
Misturse  contra  diarrhoeam  (N.  F.),  as  "Cholera  mixture," 
"  Squibb's  Diarrhoea  Mixture,"  and  others,  or  "  C.  O.  T. 
pill  "  t  containing  Camphor  1  gr.  (or  0.065  gm.).  Opium  i 
gr.    (or  0.016  gm.),  and  Tannic  acid  2  grs.    (or  0.13  gm.). 


CONSTIPATION. 

Constipation  is  a  symptom  seen  in  many  diseases,  some 
functional,  some  organic.  The  treatment  should  combat 
the  cause  or  causes  in  the  individual  case.  Hence,  a  clear 
understanding  of  every  case  is  of  prime  importance. 

CLASSIFICATION  OF  CONSTIPATION. 

I.  Obstructive  Form. 

(a)   Stricture. 

(6)   Adhesions. 

(c)   Pressure  from  tumor  or  pregnancy. 

{d)   Ptosis  with  kink. 

(e)   Acute  obstruction, 

II.  Spasmodic  Form. 

(a)   Mucous  colitis. 
(&)   Neurasthenia. 
(c)  Lead  poisoning. 

id)   Intra-abdominal   or   pelvic   inflammation, 
(e)   Fissure  of  anus. 
Ml.  Atonic  Form. 
Muscular  weakness  or  general  debility  due  to: 

1.  Fevers. 

2.  Anemia, 

3.  Cachexia. 

4.  Senile  debility. 


*  U.   S.  t.  t  Not  official. 


129 

IV.  Less  common  varieties  of  constipation  are  excluded 
from  lack  of  space. 

Diagnosis  of  stricture,  adhesions  and  ptosis  or  kink  can 
seldom  be  made  satisfactorily  without  bismuth  x-rays,  but 
x-ray  evidence  is  often  misleading. 

PRINCIPLES  OF  TREATMENT. 

A.  Treat  the  cause  while  relieving  the  symptoms. 

B.  Clear  the  intestinal  tract  thoroughly  and  keep  it  clear, 
including  the  rectum. 

C.  Soothe  or  stimulate  the  bowel  by  suitable  diet  as  re- 
quired. 

D.  Improve  habits  if  they  are  faulty. 

E.  Use  cathartics  sparingly  or  not  at  all,  and  avoid  undue 
irritation  of  the  bowel  by  them. 

F.  Prescribe  sufficient  liquid  in  definite  quantity. 

G.  Enjoin  proper  mastication  of  food  and  prescribe  false 
teeth  if  needed. 

H.  Instruct  patient  about  regularity  in  defecation. 
I.  Exercise    or    abdominal    massage,    unless    contraindi- 
cated,  may  help  sedentary  persons. 

METHODS  OF  TREATMENT  FOR  OBSTRUCTIVE 
CONSTIPATION. 

(a)  Stricture.  Operation  will  generally  be  required. 
Palliation  by  means  of  "  Russian  Oil "  by  mouth,  or  by 
rectal  injections  of  oil  followed  by  cleansing  enemata  may 
be  beneficial. 

(6)  Adhesions.  The  palliative  measures  just  mentioned 
may  suffice.  Exercise  or  massage  may  do  good.  Operation 
may  be  advisable. 

(c)  Pressure.  Palliate  or  operate  according  to  circum- 
stances. 

(d)  Ptosis.  A  suitable  abdominal  supporter  may  re- 
lieve. Other  palliative  measures  and  exercise  or  massage 
may  help.     Operation  offers  little  hope  of  relief,  as  a  rule. 

(e)  Acute  Obstruction.     Prompt  operation  is  imperative. 

METHODS  FOR  SPASMODIC  CONSTIPATION. 
Mucous   Colitis.     1.  Non-irritating   diet   composed   chiefly 
of  carbohydrate  with  a  moderate  amount  of  fat  and  a  little 


131 

easily   assimilable  proteid.     Avoid   foods  rich   in   cellulose, 
acids,  spices,  tea,  coffee  and  alcoholic  beverages. 

The  following  list  of  suitable  foods  is  hot  complete,  and 
should  not  be  followed  too  closely  in  all  cases.  The  experi- 
ence of  the  patient  may  be  valuable.  Fresh  milk,  cream,  but- 
ter, sugar,  rice,  macaroni,  sago,  tapioca,  strained  oatnleal, 
cream  of  wheat,  white  bread  or  toast,  potato,  baked,  boiled 
or  mashed,  junket,  custard,  blanc-mange,  eggs,  boiled, 
poached,  scrambled  or  shirred,  finely  minced  chicken  or 
lamb,  boiled  tongue,  or  tender  steak  if  it  can  be  well 
chewed.     Do  not  starve  the  patient. 

2.  Bowels  must  be  kept  clear  by  injections  of  oil  in  the 
evening  to  be  retained  during  the  night,  and  by  cleansing 
enemata,  preferably  of  warm  normal  salt  solution,  every 
morning. 

3.  Cathartics  are  particularly  injurious  to  an  irritated  or 
inflamed  mucous  membrane  and  abdominal  massage  maj^ 
do  more  harm  than  good.  "  Russian  Oil  "  or  Agar-agar  may 
be  useful,  and  are  non-irritating. 

4.  When  the  stools  begin  to  appear  normal  the  regimen 
can  be  relaxed.  Finally,  the  patient  can  drop  the  injec- 
tions entirely  and  return  to  a  mixed  diet  rich  in  cellulose 
and  fruit  to  stimulate  normal  defectation. 

5.  Colonic  irrigations  with  or  without  appendicostomy 
may  perhaps  be  tried  in  very  obstinate  cases.  I  have  not 
seen  them  used  and  have  never  advised  them  for  colitis 
secondary  to  chronic  constipation. 

Constipation  in  Neurasthenia  may  take  various  forms,  but 
it  is  generally  attributable  to  reflex  spasm,  and  is  fre- 
quently associated  with  colitis.  Every  case  should  be  care- 
fully classified  and  treated  according  to  its  nature.  Any- 
thing which  strengthens  the  patient  or  reduces  his  reflex 
excitability  is  likely  to  lessen  the  constipation.  Moderate 
exercise  and  abdominal  massage  may  do  good. 

Injections  of  oil  enemata,  Russian  Oil  and  Agar-agar, 
generally  act  well  as  in  colitis.  Be  sure  to  keep  the  rectum 
clear. 

Lead  Poisoning  with  Constipation.  Antispasmodic  medi- 
cation with  morphine  or  atropine  is  required. 

Intra-abdominal    or    Pelvic    Inflammation    or    Fissure    of 


13S 

the  Anus  may  cause  constipation  by  reflex  spasm.  Treat- 
ment demands  removal  of  the  cause  by  appropriate  means. 

METHODS  FOR  ATONIC  CONSTIPATION. 

Post-febrile  constipation,  being  transient,  may  be  treated 
with  mild  laxatives  for  convenience. 

Constipation  in  Anaemia,  Cachexia,  or  Senile  Debility. 
The  patient's  convenience  should  be  considered,  especially 
in  ambulatory  cases,  or  when  the  chance  of  ultimate  cure 
is  small.  Nux  vomica  may  be  of  service,  and  mild  laxa- 
tives, glycerine  suppositories,  or  enemata  may  be  advised 
according  to  circumstances.  Fsecal  impaction  should  be 
guarded  against  and  watery  catharsis  must  be  avoided-. 
Massage  may  do  good  and  mechanical  support  may  aid  de- 
fecation when  the  abdominal  wall  is  weak. 

A  diet,  rich  in  cellulose,  fruits,  and  sugar,  may  help  to 
stimulate  peristalsis.  Graham  bread,  oatmeal,  cracked 
wheat,  green  vegetables,  beets,  carrots,  turnips,  tomatoes, 
raw  or  stewed  fruits  and  jams  are  particularly  to  be  recom- 
mended for  those  who  can  digest  them. 

METHODS  USEFUL  IN  VARIOUS  KINDS  OF 
CONSTIPATION. 

I.  IVlassage  daily  may  be  very  beneficial. 
"Cannon-ball    Massage."     A  heavy  ball  is  necessary.     A 

12-  or  16-lb.  "shot"  (made  for  athletics)  and  covered  with 
leather  or  strong  cloth  will  serve.  Once  or  twice  daily  the 
patient,  lying  on  his  back,  should  roll  the  shot  repeatedly 
around  the  abdomen  from  the  caecum  along  the  course  of 
the  colon  for  15  minutes  before  going  to  the  toilet. 

II.  Enemata.  (a)  In  long-continued  constipation  the  rec- 
tum may  never  empty  itself  completely  ("  dyschezia "). 
As  a  result  the  reflex  to  defecation  may  be  lost.  This  re- 
flex can  sometimes  be  regained  after  a  course  of  injections 
of  oil  at  night,  followed  by  cleansing  enemata  in  the  morn- 
ing. Olive  or  linseed  oil  is  suitable.  From  4  to  6  oz.  (or 
fr.  120  to  180  c.c.)  should  be  used  at  each  injection  and  the 
oil  should  be  retained  through  the  night. 

(&)   Cleansing  enemata  of  warm  water  with  or  without 


< 


135 

the  addition  of  Sod.  bicarb,  or  of  salt  solution  can  be  used 
when  irritation  of  the  mucous  membrane  is  to  be  avoided. 

(c)  Cold  water,  hot  water,  or  soap  suds  and  water  are 
more  potent  than  salt  solution  or  warm  water. 

(cl)  Strong  enemata,  consisting  of  glycerine  fr.  1  drach. 
to  1  oz.  (4  to  30  c.c);  or  of  Sat.  sol.  of  Mag.  sulph., 
glycerine,  and  water  aa  2  oz.  (or  60  c.c.)  can  be  used  if  re- 
quired. 

III.  Laxatives  should  be  used  only  in  conjunction  with 
suitable  diet,  abundant  liquid  (6  to  8  glasses  of  water  daily) 
and  hygienic  habits.     No  one  laxative  suits  all  persons. 

(a)  Fl.  Ext.  of  Cascara  sagrada  can  be  used  in  doses  of 
10  or  15  min.  (or  0.6  to  1  c.c.)  after  meals,  or  in  a  single 
dose  of  fr.  10  min.  to  30  min.  (or  0.6  to  2  c.c.)  at  bed-time. 
When  regularity  of  the  bowels  has  been  established  the  dose 
of  Cascara  can  be  diminished  drop  by  drop  until  medicine 
is  no  longer  required. 

(&)  Prunes  and  Senna.  Instruct  patient  to  stew  3  dozen 
prunes  with  two  tablespoonfuls  of  Senna  leaves  (enclose 
leaves  in  a  cheese-cloth  bag),  and  to  eat  10  prunes  once  or 
twice  daily.  When  the  bowels  have  been  regular  for  a  time 
the  amount  of  Senna  can  be  reduced  until  prunes  only  are 
taken.     Later,  the  number  of  prunes  can  be  reduced. 

(c)  Russian  Oil  or  Agar-agar  may  be  tried.  They  act 
mechanically  and  do  not  irritate  the  intestines. 


CHAPTER  V. 


DRUGS. 

FOREWORD. 

He  who  masters  the  use  of  a  few  good  drugs  will  succeed 
better  than  he  who  tries  many  at  random. 

Before  prescribing  a  drug,  let  the  indications  for  its  use 
be  clear. 

Prescribe  drugs  singly  when  expedient. 

Ascertain  whether  an  idiosyncrasy  to  the  drug  you  wish 
to  prescribe  is  known  to  the  patient. 

When  a  drug  has  been  given,  watch  for  its  good  or  for  its 
toxic  effect.  Increase  dose  until  the  one  or  the  other  is  ap- 
parent. If  neither  results,  change  either  the  preparation  or 
the  drug. 

If  toxic  effects  occur,  omit  the  drug  for  a  time  and  resume 
it  later  in  smaller  dosage  or  try  a  substitute. 

EXPLANATION. 

The  purpose  of  the  list  which  follows  is  to  indicate  the 
important  drugs  and  the  preparation  of  each  believed  to  be 
the  most  generally  useful.  The  dosage  recommended  is  suit- 
able for  the  average  adult  and  may  require  modification  for 
the  individual. 

Much  useful  information  is  contained  in  the  "  United 
States  Dispensatory."  It  describes  the  drugs  of  the  princi- 
pal pharmacopoeias,  the  preparations  of  the  "  National  For- 
mulary," and  many  unofficial  preparations.  "  New  and  Non- 
official  Remedies "  gives  information  about  many  proprie- 
tary drugs.  The  writer's  information  about  patents  and 
trademarks  was  derived  from  this  book.  It  is  published  and 
sold  by  the  American  Medical  Association. 

137 


139 


ABBREVIATIONS. 

U.  S.     United  States  Pharmacopoeia,  8th  Rev. 

Br.     British  Pharmacopoeia. 

N.  F,     National  Formulary. 

U.  S.  p.  and  t.     United  States  patent  and  trademark. 

N.  N.  R.     New  and  Nonofficial  Remedies,  1914. 

U.  S.  D.     United   States  Dispensatory,   19th  Ed. 

SYNOPSIS  OF  DRUGS. 

I.     SALVARSAN.* 

Action.  Kills  certain  pathogenic  organisms  in  the  living 
body.  It  may  irritate  the  kidneys  or  liver  but  seems  to  have 
no  toxic  effect  per  se  for  other  organs. 

Elimination.  Excretion  rapid,  chiefly  in  urine  and  faeces. 
When  the  excretory  organs  act  normally,  most  of  the  drug 
Is  eliminated  on  the  first  day  and  nearly  all  within  three  or 
four  days  after  an  intravenous  injection. 

Toxic  effects.  1.  Signs  of  renal  irritation  or  diminution 
of  kidney  function. 

2.  Jaundice. 

3.  Erythema. 

4.  Hyperemia  and  swelling  at  the  site  of  syphilitic  lesions; 
i.e.,  "  Herxheimer  reaction."  To  this  group  probably  belong 
many  of  the  dangerous  symptoms  arising  within  three  days 
of  the  injection.  Among  them  may  be  mentioned  headache, 
vomiting,  earache,  syncope,  convulsions  and  coma. 

5.  Fever  developing  gradually  after  a  day  or  two  may  re- 
sult from  rapid  destruction  of  spirochsetse. 

Accidents  or  errors  which  may  cause  severe  symptoms  or 
death : 

1.  The  "  water-error,"  i.e.,  contamination  of  the  distilled 
water  (used  for  solution)  with  bacteria  living  or  dead;  or 
with  chemical  impurities  from  the  distilling  apparatus. 
Symptoms  often  attributed  to  water-error  are  rigor,  rapid 
rise  in  temperature,  gastro-enteric  disturbances,  etcf 


*  U.  S.  p.  and  t. 

t  There    are   those   who  believe   that  the   symptoms    attributed    to    the 
water-error  "    are  due  to  other  causes,   e.g.,  overdosage. 


141 

2..  Impurity  of  NaCl  or  of  NaOH  used  in  tlie  solution. 

3.  Oxidation  of  tlie  Salvarsan  may  be  followed  by  signs  of 
arsenical  poisoning,  gastro-enteric  disturbance,  peripheral 
neuritis,  paraplegia,  etc. 

4.  Accidental  use  of  an  acid  instead  of  an  alkaline  solution. 
The  former  is  10  times  more  toxic  than  the  latter. 

5.  Errors  in  technic  of  injection;  may  result  in  venous 
thrombosis  and  pulmonary  embolism. 

6.  Use  of  Salvarsan  in  unsuitable  cases. 

7.  Lack  of  preparation,  or  of  after-care  of  the  patient. 

8.  Excessive  dosage  for  the  individual  under  existing  cir- 
cumstances, or  too  early  repetition  of  dose. 

9.  Combined  effect  of  various  factors  above  mentioned.     . 

10.  Neurorecurrence.  It  appears  after  weeks  or  months 
and  is  a  recurrence  of  syphilis,  not  an  effect  of  Salvarsan. 

Indications.  Suitable  cases  of  syphilis,  relapsing  fever, 
yaws,  and  various  other  diseases.  Salvarsan  is  not  danger- 
ous when  used  wisely  and  with  the  best  technic. 

Contraindications  are  relative  rather  than  absolute.  The 
use  of  Salvarsan  is  particularly  dangerous  when  the  pa- 
tient has: 

1.  Aneurism,  coronary  sclerosis,  myocarditis,  evidence  of 
angina  pectoris,  or  other  severe  lesions  of  the  circulatory 
system. 

2.  In  non-syphilitic  nephritis. 

3.  In  diseases  of  the  liver,  pancreas,  or  adrenal  glands. 

4.  When  there  is  advanced  degeneration  of  the  nervous 
system. 

5.  Profound  anemia,  or  pronounced  cachexia  not  due  to 
syphilis. 

6.  Severe  pulmonary  lesions,  or  marked  physical  weakness 
from  any  cause. 

Caution  is  advisable  when  there  are: 

1.  Syphilitic  lesions  of  the  central  nervous  system,  or 
when  their  presence  is  indicated  by  changes  in  the  spinal 
fluid  or  suggested  by  slight  symptoms. 

2.  In  the  secondary  stage  of  syphilis. 

3.  When  the  patient  is  alcoholic. 

4.  Shortly  after  fatigue  or  exertioQ, 


143 

5.  When  excess  of  any  kind,  work,  or  travel,  cannot  be 
prevented  for  a  time  after  the  injection. 

G.  In  old  age,  or  when  there  is  advanced  arteriosclerosis. 

Administration.  An.  infusion  apparatus  consisting  of  a 
glass  receptacle  with  an  opening  at  the  bottom,  a  rubber  tube 
provided  with  a  glass  window  at  the  lower  end,  a  clamp 
and  a  needle  will  suffice.  At  the  Massachusetts  General  Hos- 
pital salt  solution  is  used  to  establish  the  flow.  When 
nearly  all  the  salt  solution  has  left  the  receptacle  the  Sal- 
varsan  is  poured  in.  Salt  solution  is  poured  in  again  to 
clear  the  needle  before  it  is  withdrawn.  Care  is  taken  to 
prevent  the  entrance  of  air  into  the  vein.  About  five  min- 
utes is  allowed  for  the  passage  of  the  Salvarsan  into  the 
vein,  and  the  rate  of  flow  is  regulated  by  the  height  of  the 
receptacle. 

This  operation  requires  strict  asepsis  at  every  step. 

Dose.  Speaking  of  the  use  of  Salvarsan  in  syphilis,  Ehr- 
lich  says:  "  The  dose  depends  entirely  on  the  type  and  stage 
of  the  disease."  Ordinarily,  fr.  0.1  to  0.6  gm.*  is  used  at  in- 
tervals of  from  5  to  10  days.  In  rare  instances  smaller  or 
larger  doses  may  be  tried. 

Caution.  When  danger  is  to  be  feared  begin  treatment 
with  a  series  of  very  small  doses  at  long  intervals,  or  an 
energetic  course  of  Mercury.  The  combined  use  of  large 
doses  of  Salvarsan  and  of  Mercury  at  the  same  time  is  be- 
lieved to  be  unsafe. 

Note. —  Alternate  courses  of  Salvarsan  and  of  Mercury  are 
to  be  recommended  for  syphilis. 

NEOSALVARSAN. 

Action.  Like  that  of  Salvarsan  but  less  powerful  in  equal 
dosage. 

Toxic  Effects.  Similar  to  those  of  Salvarsan  but  milder 
with  equal  dosage. 

Indications.  It  may  be  preferred  to  Salvarsan  because 
easier  to  prepare,  or  when  toxic  effects  are  feared. 

Contraindications.     As  for  Salvarsan, 


*  The  full  dose  of  0.6  gm.  is  being  used  less  frequently,  and  smaller 
doses  more  frequently   now   at  the   Mass.   Gen.   Hosp. 


145 

Administration.  Use  immediately,  because  contact  with 
air  causes  rapid  decomposition.  Do  not  mix  tlie  drug  until 
everything  is  prepared  and  the  needle  already  in  the  vein. 

Dose.  0.9  gm.  of  Neosalvarsan  contains  the  same  quan- 
tity of  arsenic  as  0.6  gm.  Salvarsan. 

Preparation  of  Alkaline  Solution  of  Salvarsan  for  Intra- 
venous Use. 

Printed  instructions  for  preparing  the  solution  are  pro- 
vided with  the  drug. 

Technic  of  the  Massachusetts  General  Hospital. 

1.  Everything  used  for  preparing  the  solution  is  steril- 
ized beforehand,  and  is  handled  under  strictly  aseptic  pre- 
cautions. 

2.  The  solution  is  mixed  in  an  8-oz.  bottle  which  should 
have  a  glass  stopper.  The  bottle  is  graduated  for  100  and 
for  200  c.c.  Similar  ungraduated  bottles  should  be  used  for 
dispensing. 

3.  The  drug  is  dissolved  in  the  mixing  bottle  by  hard 
shaking  with  about  50  c.c.  of  0.6  %  salt  solution  instead  of 
distilled  water.  Solution  takes  place  rapidly  without  the  aid 
of  beads. 

4.  To  a  dose  of  0.6  gm.  of  Salvarsan  thus  dissolved  5  c.c. 
of  normal  NaOH  solution  is  added  and  the  mixture  is  again 
shaken  until  perfectly  clear.  Salt  solution  is  then  added  to 
make  200  c.c;  the  dispensing  bottle  is  rinsed  with  the  solu- 
tion; the  solution  is  filtered  back  into  the  dispensing  bottle, 
and  after  insertion  of  the  stopper,  the  neck  of  the  bottle  is 
covered  with  sterile  gauze,  which  is  held  in  place  by  a  pin. 
The  drug  is  then  ready  for  use. 

Salvarsan  may  decompose  within  a  few  hours.  It  should 
be  kept  cool  until  needed,  and  should  then  be  warmed  only 
a  little. 

List  of  Things  Required  for  Preparing  Solution. 

1.  Burette  graduated  to  c.c,  containing  normal  NaOH 
solution. 

2.  Flask  of  0.6%  NaCl  solution. 


147 

3.  Glass  funnel  and  filter  paper. 

4.  One  graduated  and  one  plain  8-oz.  bottle  having  glass 
stoppers. 

5.  Basin  of  antiseptic  containing  also  the  ampule  of  Sal- 
varsan,  a  file  and  a  pin. 

6.  Sterile  sheet  and  sponges. 

2.     HYDRARGYRUM. 

"  Mercury." 

(a)  Hydrargyri  salicylas.*  "Neutral  mercuric  salicyl- 
ate." 

(&)  Hydrargyri  chloridum  corrosivum  (U.  S.).  "Corro- 
sive sublimate,"  "  Bichloride  of  mercury." 

(c)  Unguentum  hydrargyri!  (U.  S.).  "Mercurial  oint- 
ment." 

(cl)  Hydrargyri  iodidum  fiavum  (U.  S.).  "  Protiodide  or 
yellow  iodide  of  Mercury." 

Action  of  the  above  preparations  is  essentially  the  same: 
anti-syphilitic,  local  irritant,  and  antiseptic. 

Elimination.  Chiefly  by  intestines  and  kidneys;  also  in 
saliva.     Excretion  is  slow. 

Toxic  Effects:  Acute  Poisoning:  stomatitis,  salivation, 
renal  irritation,  diarrhoea,  abdominal  pain  and  gastric  dis- 
turbance. 

Chronic  Poisoning :  cachexia,  anemia,  etc. 

Indications:  Syphilis,  The  choice  of  a  mercurial  prepara- 
tion depends  on  the  stage  and  severity  of  the  disease,  the 
condition  of  the  patient,  and  the  circumstances  under  which 
the  treatment  is  to  be  carried  9ut.  Bach  of  the  four  prep- 
arations mentioned  above  has  advantages  lacking  in  the 
others. 

Contraindications.  Nephritis  unless  luetic,  cachexia,  ane- 
mia. 

Administration  and  Dose. 

(a)   Hydrargyri   salicylas:    nearly  insoluble;    single   dose 


*  Not  official  in  U.  S.  There  is  also  a  basic  salicylate  of  mercury 
(Merck).     It  is  used  at  the  Massachusetts  General  Hospital. 

t  Conts.  about  50%  of  Mercury  by  weight.  Ung.  Hydrarg.  Dil. 
(U.S.),   "  Blue  ointment,"   conts.   about  33%   of  Mercury. 


149 

fr.  10  to  15  min.  (or  0.6  to  1  c.c.)  of  a  10  %  solution  of  the 
drug  in  Petrolatum;  repeat  in  from  5  to  10  days.  Inject 
into  the  gluteal  muscle.     Use  a  platinum  needle. 

(&)  Hydrargyri  chloridum  corrosivum:  soluble;  single 
dose  fr.  7  to  15  min.  (or  0.5  to  1  c.c.)  of  a  1  %  solution  of 
the  drug  in  a  10  %  watery  solution  of  Sodium  chloride; 
repeat  in  1  or  2  days.  Inject  into  the  gluteal  muscle.  Use 
a  platinum  needle. 

(c)  Unguentum  hydrargyri:  administer  by  inunction. 
Dose  fr.  i  to  1  drach.  (or  2  to  4  gm.).  Efficiency  depends 
much  on  thoroughness  of  application. 

((Z)  Hydrargyri  iodidum  flavum;  administer  in  pills  by 
mouth.  Dose:  \  gr.  t.i.6,.  (or  0.013  gm.)  and  upward,  in- 
creasing gradually  until  the  first  signs  of  intolerance  appear. 
Then  reduce  dose  by  half  and  continue. 

Caution.  When  mercurials  are  given,  the  mouth  must  be 
kept  scrupulously  clean  to  avoid  stomatitis.  Teeth  should 
be  brushed  and  throat  gargled  after  every  meal.  If  there 
is  pyorrhoea  alveolaris,  the  gums  may  be  scrubbed  with  cas- 
tile  soap  or  swabbed  daily  with  a  1  %  solution  of  Potassium 
permanganate,  applied  with  cotton  stick;  also  rinse  or  spray 
mouth  with  Hydrogen  peroxide.  When  giving  the  Pro- 
tiodide  of  Mercury  and  Sodium  or  Potassium  iodide  also, 
give  the  Protiodide  a.  c.  and  the  Potassium  iodide  p.  c.  to 
prevent  formation  of  the  Biniode  of  Mercury.  When  using 
large  doses  of  any  mercurial,  the  bowels  should  be  kept 
clear,  and  the  food  should  be  readily  digestible,  nutritious 
and  ample  in  quantity. 

ISiOte. —  The  reader  is  advised  not  to  use  Mercury  in  large 
doses  or  by  injection  unless  familiar  with  the  details  of  its 
administration,  dosage  and  indications.  Gottheil  gives  an 
excellent  account  in  Forchheimer's  "  Therapeusis  of  Inter- 
nal Diseases." 

3.     POTASSII  IODIDUM.     (U.  S.) 

"Iodide  of  Potash." 

Properties.     White,  crystalline,  very  soluble  in  water. 
Action.     1.  Causes    disappearance    of    gummata;     but    a 


151 

lesion  which  disappears  while  iodides  are  being  taken  is  not 
necessarily  syphilitic. 

2.  Increased  fluidity  of  mucus  in  respiratory  tract.* 

3.  Tends  to  lower  blood-pressure  when  high.* 

4.  Seems  to  increase  thyroid  activity. 

Elimination.  Rapid,  chiefly  in  urine  as  salts,  partly  in 
saliva.* 

Toxic  Effects:  Acute:  Acne,  erythema,  and  other  seri- 
ous skin  lesions,  catarrh  of  respiratory  organs,  gastric  dis- 
turbances, delirium,  etc.  Chronic:  loss  of  weight,  nervous- 
ness, anemia. 

indications.     1.  Late  stages  of  syphilis. 

2.  Bronchitis  with  sticky  expectoration. 

3.  EmpiWcally  in  arteriosclerosis,  asthma,  lead  poisoning, 
simple  goitre,  and  many  other  conditions. 

Contraindications.  Acute  renal  irritation,  acute  inflam- 
mation of  the  respiratory  tract,  and  "  hyperthyroidism." 
It  may  be  harmful  in  phthisis. 

Administration.  1.  For  syphilis,  fr.  10  to  20  grs.  (or  0.6 
to  1.3  gm.)  t.i.cl.p.c.  in  milk.  For  syphilis  of  central 
nervous  system,  increase  dose  rapidly  until  beneflt  or  io- 
dism  results.  One  hundred  grains  (or  6.5  gm.)  t.  i.  d.  is 
large  enough  dosage.  The  sat.  sol.  in  water  is  convenient: 
1  min.  =  1  gr.  or  0.065  gm. 

2.  As  expectorant  give  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.) 
t.  i.  d.  p.  c.  well  diluted. 

3.  For  empirical  action  use  small  doses. 
Substitutes.     For  syphilis:    other  preparations  of  Iodine, 

Mercury,  or  Salvarsan. 

As  expectorant:  Ammonium  chloride. 

4.     DIPHTHERIA  ANTITOXIN.f 

Action.     Curative  in  diphtheria. 

Absorption.  It  is  absorbed  slowly  from  the  subcutaneous 
tissues,  the  process  lasting  for  several  days. 


*  Bastedo. 

t  Manufactured  by  Departments  of  Health  and  by  pharmaceutical 
firms.  It  can,  be  obtained  from  the  State  Board  of  Health  in  Massa- 
chusetts free  of  charge. 


153 


Toxic    Effects.     Urticaria,    erytliema,    joint-pains,    etc. 

Indications.  Clinical  diphtheria;  and  for  those  exposed 
to  diphtheria. 

Contraindications.  Never  absolute.  Dangerous  in  suffer- 
ers from  asthma,  particularly  horse  asthma.  When  a  pa- 
tient has  received  an  immunizing  dose,  and  two  weeks  or 
more  thereafter  develops  diphtheria,  the  possibility  of  ana- 
phylaxis must  be  considered,  but  the  risk  is  not  great.* 

Administration.  By  injection  into  the  loose  subcutaneous 
tissues  of  the  abdominal  wall  or  below  the  angle  of  the 
scapula. 

Dose.  The  dose  should  be  gauged  according  to  the  sever- 
ity of  symptoms,  duration  of  illness,  and  extent  and  loca- 
tion of  the  membrane.*  Large  doses  are  indicated  when 
the  larnyx,  trachea,  nasopharynx  or  nose  is  much  involved, 
and  especially  in  septic  diphtheria. 

Therapeutic  dose  for  adults,  fr.  5000  to  20,000  units.  For 
immunization,  fr.  1000  to  1500  units. 

5.     MORPHINE  SULPHAS.     (U.  S.) 

"  Morphine  "  or  "  Morphia." 

Properties.  White,  crystalline,  soluble  in  about  sixteen 
parts  water;  less  soluble  in  alcohol. 

Action.  1.  Diminishes  sensibility  to  lasting  impressions 
and    stimuli.     (Sollmann.) 

2.  Relieves   pain. 

3.  Slows  respiration  and  heart-action.     (Bastedo.) 

4.  Diminishes  metabolism. 

5.  Diminishes   peristalsis;    therefore,-  constipating. 

6.  In  acute  cardiac  dilatation  gives  relief. 

7.  In  colic  or  intestinal  spasm  it  may  act  as  a  cathartic. 
Elimination.     Chiefly  by  gastro-intestinal  tract.     Some  is 

oxidized  in  the  body. 

Toxic  Effects.     1.  Somnolence  or  stupor. 

2.  Respiration  very  slow  and  may  become  shallow  and 
irregular  (Cushny). 


*  Darlington:      "  Therapeusis  of  Internal  Diseases,"  Vol,  II,  Forcli- 
heinier. 


155 

3.  Pupillary  contraction. 

4.  Flushing  or  cyanosis  of  face. 

5.  Retention  of  urine. 

6.  During  recovery  from  drug  nausea  is  common. 

7.  Death  results  from  depression  of  respiratory  center. 
Indications.     Acute  conditions  with, — 

1.  Severe  pain. 

2.  Discomfort  preventing  sleep. 

3.  Acute  cardiac  insufficiency. 

4.  Internal  hemorrhage   (gastric,  pulmonary,  intestinal). 

5.  Persistent  vomiting. 

Contraindications.*  1.  Danger  of  forming  habit.  In 
chronic  or  recurring  non-fatal  diseases,  and  in  conditions 
which  can  be  relieved  by  milder  means,  use  morphine  with 
caution  if  at  all. 

2.  When  bronchial  secretion  is  profuse,  morphine  may 
prevent  necessary  expectoration:   see  pneumonia,  p.  87. 

3.  Idiosyncrasy:   causes  excitement,  vomiting,  depression. 
Administration.     For    urgent   conditions    give    subcutane- 

ously  in  the  dose  of  fr.  J  to  i  gr.  (or  0.008  to  0.032  gm.), 
with  or  without  atropine  sulphate,  fr.  i/^oo  ^o  i/^20  S^-  (^^ 
0.00032  to  0.00052  gm.).  Morphine  is  generally  given  by 
mouth  in  tablet,  in  watery  solution,  or  in  a  mixture. 
Morphine  can  be  absorbed  from  the  mouth  and  will  then  act 
more  quickly  than  if  swallowed.  Atropine  given  with  mor- 
phine tends  to  diminish  the  gastric  disturbance  which  may 
follow.  Atropine  produces  toxic  symptoms  if  repeated 
often. 

Substitutes.     Opium  in  pill,  as  tincture,  or  in  suppository. 

1.  Pilulse  opii  (U.  S.)  :  conts.  opium  1  gr.  (or  0.065  gm.) 
(  =  morphine  i  gr.  or  0.008  gm.). 

2.  Tinctura  opii  deodorati  (U.  S.).  Dose  fr.  5  to  15  m. 
(or  0.3  to  1  c.c). 


*  Codman  believes  that  morphine  after  abdominal  operations  may  in- 
duce gastric  dilatation ;  and  Bastedo  says  it  should  not  be  used  when 
there  is  "  much  depression  of  respiration,  as  in  edema  of  the  lungs, 
Cheyne-Stokes  breathing,  and  some  cases  of  pneumonia,"  or  in  "  acute 
dilatation  of  the  stomach  or  bowels."  "  It  should  be  employed  cau- 
tiously in  nephritis,  especially  if  there  is  any  uremic  tendency,"  and 
in  "  infancy  and  old  age." 


157 

3.  Tinctiira  opii  campliorata  (U.  S.) — "Paregoric." 
Dose  for  adult  fr.  1  to  4  dr.   (or  4  to  16  c.c). 

4.  Codeinse  sulphas  (U.  S.).  Dose  J  to  *  gr.  (or  0.008  to 
0.032   gm.). 

5.  Hyosclnse  hydrobromidum  (U.  S.).  Dose  fr.  3^50  to 
Moo  ST.  (or  0.00033  to  0.00065  gm.)  subcutaneously.  Com- 
bined with  morphine  it  may  act  better  than  either. 


6.     TINCTURA  DIGITALIS.     (U.  S.) 
"  Tincture  of  Digitalis." 

Action.     1.  Increases  force  of  cardiac  systole. 

2.  Lengthens  diastole  and  slows  heart  action. 

3.  Raises  blood-pressure  if  pressure  is  low. 

4.  Promotes  diuresis  when  there  is  dropsy. 
Absorption  slow;  therefore,  24  hours  or  more  is  required 

for  result.  Action  may  be  cumulative  because  excretion  is 
slow. 

Toxic  Effects.  Tachycardia  or  bradycardia,  with  irregu- 
larity, heart-block,  pulsus  alternans,  fall  of  blood-pressure, 
oliguria,  vomiting,  headache.     . 

Indications.  Myocardial  insufficiency  in  general,  with  or 
without  valvular  disease.  Almost  useless  in  circulatory 
weakness  resulting  from  vascular  dilatation  or  from  deple- 
tion. 

Tachycardia,  per  se,  does  not  call  for  digitalis. 

Contraindications.  When  increase  of  blood-pressure 
would  be  dangerous,  e.g.,  cerebral  hemorrhage. 

When  heart-block  is  developing  use  digitalis  cautiously 
if  at  all. 

Administration.     Prescribe  with  water  p.  c. 

Ordinary  dose:  fr.  5  to  20  m.  t.  i.  d.  (or  0.32  to  1.3  c.c). 
If  preparation  is  weak,  higher  dosage  may  be  required. 
Tincture  should  be  made  from  active  leaves  and  should  be 
fresh. 

When  quick  action  is  required,  fr.  20  to  30  min.  (or  1.3 
to  2  c.c.)  may  be  injected  intramuscularly.  It  is  a  local 
irritant. 

To  prevent  cumulative  effect,  keep  bowels  free. 


159 

Substitutes.  1.  "  Digipuratum."  *  Dose  fr.  1  to  4  tab- 
lets in  twenty-four  hours.  Each  tablet  contains  1^  grs. 
(or  0.097  gm.)  of  digipuratum  and  is  about  equal  in 
strength  to  15  m.  (or  1  c.c.)  of  the  most  active  tincture 
of  digitalis.  Its  therapeutic  action  is  like  that  of  the 
tincture  but  the  effect  comes  more  quickly  and  digestive 
disturbance  is  rare.  This  drug  should  act  in  fr.  12  to  24 
hours. 

"  Digipuratum-solution "  can  be  obtained  in  vials,  each 
containing  1^  grs.  (or  0.097  gm.)  of  the  drug,  and  this  dose, 
or  half  of  it,  "can  be  injected  intramuscularly.  The  effect 
can  then  be  expected  in  about  half  an  hour.  The  same 
preparation  acts  in  about  10  minutes  when  used  intraven- 
ously. The  injection  should  be  given  very  slowly.  Single 
dcses  of  fr.  |  to  1^  grs.  (or  0.05  to  0.097  gm.)  can  be  used 
intravenously. 

2.  Strophanthinum  (U.  S.).t  Action  on  heart  is  like  digi- 
talis but  effects  are  sudden  and  profound.  Death  may  re- 
sult if  the  patient  has  taken  any  preparation  of  the  digi- 
talis group  within  one  week.  On  account  of  local  irritant 
action  strophanthin  should  be  used  intravenously,  and  to 
avoid  shotk  the  injection  should  be  given  very  slowly  over 
a  period  of  not  less  than  5  minutes.  Dose  fr.  0.0005  to 
0,001  gm. 

7.     NITROGLYCERIN.! 
"  Glonoin,"  "  Trinitrin." 

Action.  Lowers  blood-pressure  by  dilating  peripheral  ves- 
sels. Acts  within  a  few  minutes;  effect  lasts  about  i  hour. 
In  the  presence  of  hypertension  diuresis  may  result. 

Toxic  Effect.  Flushing,  sense  of  fulness  in  head,  throb- 
bing headache,  faintness.     Reduction  of  urinary  output. 


*  U.  S.  p.  and  t. ;  expensive.  Caesar  &  Loretz  powdered  digitalis 
leaves  are  excellent  and  less  expensive.  Parke,  Davis  &  Co.'s  Tincture 
is  good. 

t  Boehringer's  is  good.  It  is  marketed  in  vials  containing  0.001  gm. 
of  the  drug  in  solution. 

t  Official  only  in  the   form   of   Spiritus  glycerilis  nitratis    (U.S.). 


161 

Indications.     Angina  pectoris. 

Cardiac  embarrassment  1     ,         ,       .     ,  .  , 

^     ,  ^when  due  to  high  pressure. 

Headache.  J 

Contraindications.     Low  blood-pressure. 

Administration.  Tablet  triturate.  For  quick  absorption 
the  tablet  should  be  chewed  and  not  swallowed. 

Ordinary  dose,  Y^qq  gr.  (or  0.00065  gm.)  may  be  repeated 
frequently  unless  toxic  symptoms  result. 

For  some  cases  i^qo  sr.  (or  0.00032  gm.),  or  V^q  gr.  (or 
0.0013  gm.)    is  better.     Larger  doses  may  be  required. 

Substitutes.     1.  Amylis  nitris    (U.    S.).     "  Amyl  nitrite." 

Dose  3  to  5  min.   (or  0.18  to  0.3  c.c). 

Acts  very  rapidly.     Effect  very  transient. 

May  act  when  nitroglycerin  fails. 

Put  up  in  "pearls"  containing  3  or  5  min.  (0.2  or  0.3 
c.c). 

Break  pearl  and  inhale  from  handkerchief. 

Pearls  *  should  break  easily  but  not  spontaneously. 

2.  Sodii  nitris   (U.  S.).     "Sodium  nitrite." 

Action   like   nitroglycerin,  but   lasts   longer. 

Best  prescribed  in  watery  solution. 

Dose,  2  grs.    (or  0.13  gm.). 

8.     "THEOBROMINE  SODIUM  SALICYLATE."  t  (j^u. 

Properties.  White  pwd.  v.  sol.  in  water,  taste  unpleas- 
ant, turn  brown  on  exposure  to  air. 

Action.  Diuretic;  slightly  irritating  to  the  kidneys.  Ef- 
fect is  produced  in  from  twelve  to  forty-eight  hours;  lasts 
for  from  two  to  three  days. 

Toxic  Effect.     Vomiting. 

Indications.  Cardiac  dropsy.  (Useless  or  nearly  so  in 
pure  renal  dropsy.) 

Contraindications.     Acute  nephritis. 

Administration.     In  capsules  or  in  a  cachet  p.  c. 

Dose,  15  grs.  (or  1  gm.)  4  i.  d.  If  no  result  after  48 
hours,  double  dose. 


*  Allen   &   Hanbury's   are   good. 

t  A  double  salt  of  theobromine-sodium  and  sodium  salicylate.  It  is 
official  in  Germany,  (N.N.R.).  ''  Diuretin  ''  is  the  "  trade  name  ''  of 
a    similar   proprietary    remedy. 


163 

Substitutes.  1.  Fluidextractum  apocyni  (U.  S.)  or 
"  Canadian  hemp,"  Action  diuretic  and  like  that  of  digi- 
talis but  milder.  Dose,  fr.  5  to  15  m.  (or  0.3  to  1  c.c). 
Effects  occasionally  dangerous.  Better  prescribed  as  a 
fresh  infusion  (Wheatley)  corresponding  dose,  fr.  5  to  10 
min.  (or  0.3  to  0.6  c.c). 

2.  Theophylline.*  Dose  fr.  3  to  6  grs  (or  0.2  to  0.4 
gm.)   t.  i.  d.  in  powder  with  water  or  in  capsule. 

3.  If  kidneys  are  sound,  Calomel  may  be  used  in  the  dose 
of  3  grs.  (or  0.2  gm.)  every  four  hours  for  from  twenty-four 
to  forty-eight  hours  or  even  longer.  To  reduce  danger  of 
salivation  take  precautions  described  under  Hydrargyrum. 

9.     MAGNESII  SULPHAS.     (U.  S.) 
"  Salts,"  "  Epsom  Salts  "  or  "  Bitter  Salts." 

Properties.  Colorless,  crystalline,  very  soluble  in  water, 
taste  bitter. 

Action.  Hydrogogue  purge.  Ordinarily,  it  is  not  ab- 
sorbed. 

Toxic  Effects.  Gastric  irritation  and  vomiting.  If  given 
in  concentrated  solution  it  may  be  absorbed  and  may  then 
cause  severe  poisoning  characterized  by  oliguria,  hematuria, 
slow  respiration,  paralysis  of  the  intestines,  extreme  weak- 
ness and  collapse. t  The  urine  in  poisoning  shows  a  very 
high  specific  gravity  owing  to  the  excretion  of  the  drug 
by  the  kidney.     These  effects  are  rare. 

Contraindications.  Weakness,  emaciation,  vomiting, 
menstruation,  pregnancy. 

Administration.  Most  easily  taken  in  a  cup  of  black  cof- 
fee and  most  effective  when  taken  1  hour  before  breakfast 
or  when  the  stomach  is  empty. 

Dose.  From  i  to  1  oz.  (or  15  to  30  gm.)  followed  by  half 
a  glass  of  water.  Small  doses  with  much  water  can  be 
used  for  mild  catharsis. 

Substitutes.     1.  Croton  oil,  fr.  1  to  3  min.   (or  0.06  to  0.2 


*  Not   official.     Under   the   name   of    "  Theocin  "    it   bears   U.    S.   p. 
and  t.    (N.N.R.). 

tBoos:   Jr.  A.M.A.,   Dec.   10,    1910. 


165 

c.c.)  in  pellet  of  butter.     If  placed  on  the  back  of  the  tongue 
of  an  unconscious  patient  it  will  be  swallowed. 

2.  Pot.  bitartrate  and  Comp.  jalap,  pwd.  aa  drach.  1  (or 
4  gm.). 

3.  Elaterium    (Br.)    J   gr.    (or  0.016  gm.)    in  tablet. 

4.  "  Ten-ten,"  calomel  and  jalap,  aa  grs.  10  (or  0.65 
gm.). 

ID.     QUININE  SULPHAS.     (U.  S.) 
"  Quinine." 

Properties.  White,  cryst.,  slightly  sol.  in  water,  taste 
very  bitter. 

Action.  Specific  for  malaria,  antipyretic;  readily  ab- 
sorbed, and  rapidly  eliminated  in  urine. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema; 
occasionally  renal  irritation,  amblyopia,  or  cardiac  depres- 
sion. 

Indications.     Malaria. 

Contraindications.  Idiosyncrasy  but  patients  are  fre- 
quently mistaken  in  believing  they  cannot  take  quinine. 

Administration.  In  capsule  p.  c.  Dose,  fr.  5  to  10  grs. 
(or  0.32  to  0.65  gm.)  from  2  to  4  i  cl.  Larger  doses  may 
be  required. 

Substitute.  1.  Quininse  hydrochloridum  (U.  S.)  *  fr.  7  to 
10  grs.  (or  0.5  to  0.65  gm.)  daily,  dissolved  in  water  and 
given  intramuscularly,  or  30  grs.  (or  2  gm.)  in  enema 
(Manson). 

2.  Craig  recommends  for  pernicious  malaria  intramuscu- 
lar injections  of  Quinine  bihydrochloride  f  grs.  7*  (or  0.5 
gm.)  dis.  in  water,  15  min.  (or  1  c.c.)  and  repeat  every  4 
hours  if  necessary. 

3.  Quinine  and  urea  hydrochloride  t  is  more  soluble  and 
has  been  recommended  in  recent  years.  It  is  much  used 
in  surgery  as  a  local  anaesthetic  and  can  be  obtained  in 
sterile  solution  in  vials. 


*  Soluble   in   35   parts  water. 
t  Not   official. 


167 


II.     SODII  SALICYLAS.     (U.  S.) 

Properties.  A  white  powd.  sol.  in  water,  taste  sweetish 
and  saline. 

Action.  Analgesic,  antipyretic,  and  diaphoretic.  It  has  a 
curative  effect  in  some  forms  of  rheumatism.  It  increases 
nitrogen  elimination  in  the  urine  and  acts  as  a  cholagogue 
and  diuretic.  It  is  readily  absorbed  and  is  eliminated  by 
the  kidney. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema, 
delirium  and  gastro-enteric  disturbance.  It  is  slightly  ir- 
ritating to  the  kidneys  and  unless  given  with  alkali  may 
cause  albuminuria.  Very  large  doses  may  cause  drowsiness 
or  coma. 

Indications.  Rheumatic  fever  and  various  forms  of 
"  rheumatism."  Useless  in  the  gonorrhoeal  and  in  some 
other  types  of  arthritis.  It  may  be  tried  in  large  doses  for 
infectious  endo-  or  pericarditis  or  for  chorea. 

Contraindication.     Acute  nephritis  or  idiosyncrasy. 

Administration.  In  tablet  or  capsule  followed  by  a  fioll 
glass  of  loater  unless  the  heart  be  insufficient.  If  large 
doses  are  to  be  used  prescribe  also  enough  sodium  bicar- 
bonate to  render  the  urine  alkaline  and  see  that  the  bowels 
be  kept  free. 

Dose.  For  rheumatic  fever,  10  grs.  (or  0.65  gm.)  of  so- 
dium salicylate  every  hour  until  the  patient  is  relieved  of 
pain;  then  10  gr.  (or  0.65  gm.)  every  4  hours  until  convales- 
cence has  been  established;  then  fr.  20  to  30  grs.  (or  1.3 
to  2  gm.)  daily  for  a  month  or  more  to  prevent  relapse.  If 
toxic  effects  occur  the  medicine  must  be  omitted  until  they 
pass  off.  It  can  then  be  resumed  in  smaller  dosage  or  in 
different  form.  A  vehicle,  such  as  essence  of  pepsin,  may 
be  helpful.  For  mild  cases  of  arthritis  smaller  doses  may 
be  sufficient.  In  chronic  "  rheumatism "  fr.  5  to  10  grs. 
(or  0.3  to  0.65  gm.)  taken  fr.  2  to  4  i.  d.  may  promote  com- 
fort. 

Substitute.  1.  Salicinum.  (U.  S.)  Action  and  uses  like 
sodium  salicylate  but  weaker  and  causes  less  gastric  dis- 
turbance. 

2.  Oleum    gaultherise.      (U.    S.)      "Oil    of    wintergreen." 


169 


Should  be  given  in  milk,  or  in  capsule.     Dose,  fr.  15  to  30 
min.  (or  1  to  2  c.c). 

3.  Aspirin:  *  Acetylsalicylic  acid.  Incompatible  with 
heat,  moisture,  alkalies,  their  carbonates  and  bicarbonates 
(N.  N.  R.)     Dose  as  for  sodium  salicylate. 

12.     HEXAMETHYLENAMINA.     (U.  S.)  f 

Properties.     Crystalline,  readily  sol.  in  water. 

Excretion.  Chiefly  in  the  urine  in  the  form  of  ammonia 
and  formaldehyde  or  unchanged. 

Action.  When  formaldehyde  $  is  set  free  it  acts  as  a  uri- 
nary antiseptic.  When  the  drug  is  excreted  unchanged, 
as  often  happens,  it  is  inefficient.  It  acts  only  in  an  acid 
urine. 

Toxic  Effects.  Renal  irritation  and  hematuria,  painful 
micturition  and  pain  in  the  region  of  the  bladder. 

Indications.  Especially  useful  in  typhoid  fever  to  pre- 
vent bacilluria  and  cystitis.  It  may  act  well  in  other  cases 
of  cystitis  or  pyelitis. 

Contraindication.     Acute  nephritis. 

Administration.  In  capsule  or  tablet.  Dose  from  5  to  10 
grs.  (or  0.3  to  0.6  gm.)  t.  i.  d.  with  a  full  glass  of 
water.  When  the  urine  is  alkaline  or  neutral  acid  sodium 
phosphate  can  be  prescribed  to  change  its  reaction,  but  this 
drug  should  not  be  administered  ivitli  Hexamethylenamine 
because  they  are  incompatible   (Bastedo). 

VALUABLE  DRUGS. 

13.  Pilulae  ferri  carbonatis.     (U.S.)     "  Blaud's  Pill." 

Action:  rubifacient,  slightly  constipating,  turns  stools 
black. 

Used  especially  in  chlorosis  and  secondary  anemias. 

Dose:  pills  of  5  grs.  each  (or  0.3  gm.'O  ;  fr.  1  to  2  t.  i.  d., 
p.  c. 


*  U.  S.  p.  and  t. 

t  "  Urotropine, ' '     "Fonnin,''    and    ' '  Aminof orm  ' '    are   proprietary 
names    applied    to    Hexamethylenamina.      (N.jST.R. ) 
t  May  give   Fehling's  reaction.      (Bastedo.) 


171 


Substit.  1.  Tr.  ferri  chloridi.  (U.  S.)  Dose,  fr.  5  to  30 
m.  (or  0.3  to  2  c.c.)  taken  through  a  glass  tube. 

2.  Liquor  ferri  et  ammonii  acetatis.  (U.  S.)  "  Basham's 
mixture."     Dose,  1  dr.  (or  4  c.c). 

14.  Sulphonethylmethanum.     (U.  S.)     "Trional." 
Action:   hypnotic,  sol.  in  195  water,  more  soluble  in  al- 
cohol. 

Toxic  Effect:  somnolence  and  mental  and  physical  depres- 
sion. 

Used  for  insomnia,  sometimes  for  alcoholic  delirium. 

Dose:  for  sleep,  fr.  5  to  15  grs.  (0.3  to  1  gm.)  in  powd. 
by  mouth.     Larger  doses  may  be  used  for  delirium. 

Prescribed  in  powder  by  mouth  with  water  or  in  sol.  by 
rectum. 

Substit.  "Veronal."  (U.  S.  pat.)  Dose,  as  for  trional 
in  powd.  or  tab. 

15.  (a)  Sodii  bromidum.  (U.  S.)  "Sodium  bro- 
mide." 

(b)  Potassii  bromidum.  (U.  S.)  "Potassium 
bromide," 

Action:  Mild  sedative,  lessens  reflex  excitability.  Slightly 
irritating  to  the  stomach. 

Toxic  Effect:   Vomiting,  acne,  coryza,  somnolence. 

Used  for  nervousness,  insomnia,  epilepsy,  and  to  ward 
off  alcoholic  delirium. 

Dose:  Usually  fr.  5  to  15  grs.  (or  0.3  to  1  gm.)  t.  i.  d., 
or  a  single  dose  at  night  for  sleep. 

Much  larger  doses  may  be  required  for  epilepsy  and  for 
alcoholic  patients. 

Prescribed  in  watery  solution  by  mouth  well  diluted  and 
p.  c,  or,  occasionally,  by  rectum. 

16.  Acetphenetidinum.     (U.  S.)     "  Phenacetin."  * 
Action:  analgesic,  antipyretic,  mild  diaphoretic,  and  seda- 
tive. 

Toxic  Effect:  circulatory  depression. 
Used  especially  for  migraine  and  occasionally  for  other 
painful  conditions. 

Dose:   fr.  5  to  15  grs.    (or  0.3  to  1  gm.)    in  tab.  or  pow- 


Bayer's  is  the  best. 


173 


der.  A  small  dose  may  be  repeated  in  an  hour  or  more  if 
necessary.  Prescribe  with  caffein  citrate,  1  gr.  (or  0.065 
gm.). 

17.  Pulvis  ipecacuanhae  et  opii.  (U.  S.)  "Dover's 
Powder." 

Action:  Mild  opiate:  hypnotic,  sedative,  diaphoretic,  an- 
tipyretic and  analgesic;  slightly  constipating. 

Toxic  Effect:  When  stomach  is  irritable  vomiting  may 
result. 

Used  generally  in  single  dose  in  the  evening  for  malaise 
or  insomnia  in  acute  infections  such  as  "  grippe,"  tonsillitis, 
or  the  exanthemata. 

Dose:  fr.  10  to  15  grs.  (or  0.6  to  1  gm.)  in  pwd.  by 
mouth, 

18.  Codeinas  sulphas.     (U.  S.)     "Codeine." 

Action:  mild  opiate  and  sedative.     Slightly  constipating. 
Toxic  Effect:  vomiting,  generally  on  following  day. 
Used  to  allay  unproductive  cough. 

Dose:  fr.  i  to  *  gr.  (or  0.008  to  0.032  gm.)  in  tablet,  by 
mouth. 

19.  Sodii  bicarbonas.     (U.S.)     "Soda."    "  Saleratus." 
Action:  antacid. 

Toxic  Effect:   gastric  disturbance,  not  poisonous. 

Used  for  "  hyperacidity,"  in  acidosis,  and  in  acid  poison- 
ing; to  render  urine  alkaline;  and  with  salicylate  in  acute 
rheumatism. 

Dose:  fr.  1  to  1  dr.  (or  2  to  4  gm.)  3  or  4  i.  cl.  with  water 
by  mouth.     Larger  doses  may  be  required  in  acidosis. 

20.  Bismuthi  subnitras.     (U.  S.)     "Bismuth." 
Action:    mild    astringent    and    antacid.     Combines    with 

H2S  in  intestine  to  form  a  black,  insoluble  sulphide. 

Toxic  Effect:  none  with  therapeutic  dose. 

Used  for  diarrhoea,  "  hyperacidity,"  peptic  ulcer,  and  for 
intestinal  fermentation. 

Dose:  for  diarrhoea  fr.  10  to  20  grs.  (or  0.65  to  1.3  gm.) 
repeated  after  each  loose  movement.  For  peptic  ulcer  * 
doses  of  1  dr.  (or  4  gm.)  are  used  a.  c.  to  coat  the  ulcer  and 


*  Use  a  pure  preparation:   e.  g.,  Squibb's. 


175 

to   relieve    distress.     Prescribed   in   powd.   by   mouth   with, 
water. 

21.  Hydrargyri  chloridum  mite.     (U.S.)    "Calomel." 
Action:   Mild  purgative  and  supposed  intestinal  antisep- 
tic.    Diuretic.     Antisyphilitic. 

Toxic  Effects:  renal  irritation,  stomatitis,  etc.   (p.  149). 

Use  and  Dose:  1.  as  a  mild  purge,  either  in  the  dose  of 
J^  gr.  (or  0.006  gm.)  every  15  m.  for  8  or  10  doses  and 
followed  by  a  mild  saline  cathartic  1  hour  after  the  last 
dose,  or  fr.  1  to  3  grs.  (or  0.065  to  0.2  gm.)  can  be  taken 
in  single  dose  at  night  and  the  saline  on  the  following 
morning. 

2.  As  a  diuretic:  3  grs.  (or  0.2  gm.)  every  4  hours  for 
fr.  24  to  48  hours  or  until  diuresis  begins.  When  using 
this  dose  the  usual  precautions  against  poisoning  must  be 
taken   (p.  149).     Prescribe  in  tablet. 

3.  Calomel  is  preferred  by  many  to  salicylate  of  mercury 
for  the  treatment  of  syphilis  by  injection. 

22.  Oleum  ricini.     (U.  S.)     "Castor  oil." 

Action:  mild  purgative;  acts  in  fr.  2  to  6  hours;  after 
effect  constipating.  Do  not  prescribe  it  during  menstrua- 
tion or  pregnancy. 

Toxic  Effect:  not  poisonous  but  may  be  vomited. 

Dose:  fr.  i  to  2  ozs.  or  more  (15  to  60  c.c).  Lemon 
juice  or  brandy  helps  to  disguise  the  taste. 

23.  Fluidextractum  rhamni  purshianae.  (U.  S.) 
"  Fl.  ext.  of  cascara  sagrada." 

Action:  mild  laxative.     Taste:  very  bitter. 
Toxic  Effect:  irritation  of  bowel. 

Dose:  fr.  10  to  30  m.  (or  0.6  to  2  c.c.)  at  bed-time  with 
water. 

24.  Vaccine  virus. 

The  living  virus  of  cow-pox  is  used  as  a  prophylactic 
against  small  pox.  The  virus  should  be  fresh,  and  a 
"  take "  or  lesion  of  cow-pox  is  required  to  confer  im- 
munity. 

Admin.  1.  Clean  skin  with  soap  and  water.  Antiseptics, 
if  used,  must  be  washed  off  lest  they  kill  the  virus. 

2,  When  dry,  scarify  skin  very  superficially  without  caus- 


177 

ing  bleeding.     A  needle  or  any  sharp  instrument  will  serve. 

3.  Apply  virus.  After  it  has  dried  completely  cover  the 
spot  with  a  sterile  pad  and  secure  it  with  adhesive  plaster. 

4,  When  the  inoculation  "  has  taken "  the  lesion  should 
be  bathed  with  antiseptics  and  dressed  aseptically  from 
time  to  time.  Secondary  infection  and  much  pain  can  thus 
be  avoided. 

Note. —  Virus  is  prepared  by  health  departments  nearly 
everywhere  and  is  distributed  free  to  physicians. 

25.  Typhoid  vaccine. 

A  killed  culture  of  typhoid  bacilli  standardized  by  count. 
Used  for  prophylactic  inoculation  against  typhoid    (p.  65). 

In  general,  three  doses  are  given  subcut.  at  intervals  of 
a  week  or  ten  days  as  follows:  500  million,  1,000  million, 
and  1,000  million. 

The  reaction  is  seldom  severe.  There  may  be  fever  and 
malaise. 

The  interval  between  injections  should  not  be  longer  than 
10  days  lest  anaphylaxis  result. 

Inoculation  is  strongly  recommended  for  persons  who 
travel,  for  nurses,  physicians,  soldiers  and  others  who  may 
be  exposed  to  typhoid  infection. 

Note. —  Prepared  by  health  departments  *  and  pharma- 
ceutical firms. 

26.  Tuberculin. 

Used  for  diagnostic  tests  and  for  treatment  in  suitable 
cases  of  tuberculosis.  For  detailed  information  see  "  Early 
Pulmonary  Tuberculosis;  Diagnosis,  Prognosis,  and  Treat- 
ment," by  John  B.  Hawes  2nd,  M.D.     (Wm.  Wood  &  Co.) 

There  are  several  kinds  of  tuberculin.  Koch's  old  tuber- 
culin is  a  glycerine  extract  of  tubercle  bacilli.  It  is  still 
used  extensively. 

27.  "  Normal  salt  solution." 

Used  by  hypodermoclysis,  intravenously,  or  by  rectum, 
depending  upon  circumstances  and  object  in  view. 

The  common  solution  consists  of  0.6%  of  sodium  chloride 
in  distilled  water. 

Solutions  are  prepared  also  according  to  other  formulae 


*  Distributed  free  in  Massachusetts  by  the  State  Board  of  Health. 


179 

which,  contain  calcium  and  potassium  chloride  in  addition 
to  sodium  chloride. 

When  prescribing  specify  formula  desired. 

28.  Alcoholic  beverages. 

A.  (a)   Spiritus  frumenti.     (U.  S.)     "Whiskey." 
(&)   Spiritus  vini   Gallici.      (U.   S.)      "Brandy." 

Uses  : 

1.  Quickly   diffusible  stimulant;    dose   by  mouth,   fr.   1 

drach.   to   1   oz.    (or  4   to  30   c.c).     Dose   subcut., 
30  min.    (or  2   c.c). 

2.  To   promote   appetite;    best   taken   with   meals    and 

well  diluted, 

3.  As  a  food  in  malnutrition  when  other  foods  are  not 

absorbed   in   sufficient   quantity.     Alcohol    is   espe- 
cially useful  in  selected  cases  of  typhoid  or  septic 
infection. 
Dose  fr.  1  to  2  oz.  (or  30  to  60  c.c.)   diluted  with  water 
and  repeated  at  intervals  of  fr.  2  to  6  hours.     Larger  doses 
are  sometimes  beneficial. 

If  odor  remains  on  breath  reduce  dose  or  lengthen  in- 
terval. 

Champagne    is    often    borne    better    than    whiskey    or 
brandy  when  the  stomach  is  irritable. 

B.  Beer,  ale,  porter,  or  malt  may  be  prescribed  with 
meals  to  improve  appetite  and  to  promote  increase  of 
weight. 

29     ''RUSSIAN  OIL" 

Petrolatum  licLuidum  (U.  S.)  and  "Russian  Oil"  are 
liquid  paraffins  under  the  definition  of  the  British  Pharma- 
copoeia, but  "  Russian  Oil "  is  not  liquid  petrolatum  be- 
cause of  a  difference  between  Russian  and  American  Pe- 
troleum. "  Russian  Oil  "  is  more  refined  than  is  ordinarily 
the  case  with  liquid  petrolatum.  The  latter  usually  has  a 
yellowish  color  and  an  unpleasant  taste,  but  the  former 
is  colorless  and  tasteless. 

Substitutes  for  "  Russian  Oil  "  should  have  similar  gen- 
eral characteristics,  should  be  tasteless,  and  of  high  specific 
gravity.  Lighter  oils  seem  less  efficient,  and  sometimes  es- 
cape through  the  anus  involuntarily. 


181 


Action:  A  lubricant  which  passes  unabsorbed  and  un- 
digested through  the  intestine.  Unlike  olive  oil  it  is  not 
a  food,  and  is  less  apt  to  disturb  the  digestion. 

Used  chiefly  in  chronic  constipation,  alone  or  in  con- 
junction with  other  forms  of  treatment. 

Dose  from  1  to  3  tablespoonfuls  twice  daily;  preferably 
several  hours  after  a  meal. 

30     AGAR-AGAR 

Action:  Agar-agar  swells  tremendously  by  absorbing 
water,  is  not  digested,  and  does  not  ferment  in  the  intes- 
tinal tract.  Therefore,  it  stimulates  peristalsis  and  helps 
to  sweep  out  the  bowel. 

Used  in  chronic  constipation,  generally  in  conjunction 
with  other  forms  of  treatment. 

Dose  from  i  to  1  tablespoonful  once  or  twice  daily. 

Administration:  Powdered  agar  can  be  eaten  on  cereal. 
Granulated  agar  can  be  mixed  with  and  washed  down  with 
milk  or  water.  Agar-agar  wafers  are  more  attractive  but 
expensive. 

DRUGS  VALUABLE  FOR  OCCASIONAL  USE. 

1.  Thyroid  extract."^ 

2.  Liquor  potassii  arsenitis.     (U.   S.)      "  Fowler's 

solution." 

3.  Pilocarpinae  hydrochloridum.     (U.  S.) 

4.  Apomorphinae  hydrochloridum.     (U.  S.) 

5.  Vinum  colchici  seminis.     (U.  S.) 

6.  Quininae  hydrobromidum.     (U.  S.) 

7.  Hyoscinae  hydrobromidum  (U.  S.)       fchemically 
Scopolaminae  hydrobromidum  (U.  S.)  l^the  same. 

8.  Caffeinae  sodio-salicylas.     (N.  F.) 

9.  Oleum  tiglii.     (U.  S.)     "  Croton  oil." 

10.  Elaterium.     (Br.) 

11.  Adrenalin  chloride  solution,t  i  to  1,000. 


*  Not  official.     Burrough's,  Welcome  &  Co.'s  extract  is  good. 
t  U.  S.  t.     Parks,  Davis  &  Co. 


183 

12.  Cocainae  hydrochloridum.      (U.  S.) 

13.  Atropinas  sulphas.     (U.  S.) 

14.  Strophanthinum.      (U.  S.)  * 

15.  Apocynum.     (U.  S.) 

16.  Emetine  hydrochloride,  f 

DRUGS  IN  COMMON  USE. 

1.  Tinctura  ferri  chloridi.      (U.  S.) 

2.  Liquor    ferri     et    ammonii     acetatis.      (U.     S.) 

"  Basham's  mixture." 

3.  Spiritus  aetheris  compositus.     (U.  S.) 

"  Hoffmann's  anodyne." 

4.  Spiritus  ammoniae  aromaticus.      (U.  S.) 

5.  Potassii  bitartras.      (U.  S.)     "  Cream  of  tartar." 

6.  Potassii  citras.      (U.  S.) 

7.  Pilula  scillas  composita.      (Br.) 

8.  Liquor  antisepticus  alkalinus,      (N.  F.) 

"  Alkaline  antiseptic." 

9.  Liquor  sodii  boratis  compositus.     (N.  F.)     "  Do- 

bell's  solution." 

10.  Caffeina  citrata.     (U.  S.) 

11.  Strychninae  sulphas.      (U.  S.) 

12.  Tinctura  nucis  vomicae.      (U.  S.) 

13.  Syrupus  hypophosphitum.      (U.  S.) 

"  Syrup  of  hypophosphites." 

14.  Syrupus  hypophosphitum  compositus.      (U.  S.) 

"  Compound  syrup  of  hypophosphites." 

15.  Phillips'  Milk  of  Magnesia.? 

16.  Senna.      (U.  S.)      "  Senna  leaves." 

17.  Glycerinum.      (U.  S.) 

18.  Tinctura  iodi.      fU.  S.) 

19.  Tinctura  belladonnae  foliorum.      (U.  S.) 

20.  Pilulae    catharticae   compositae.   (U.  S.) 

"  Compound  Cathartic  Pills." 

21.  Pilulae  aloini,  strychninae,  et  belladonnae. 

(N.  F.)      "A.  S.  and  B.  Pills." 

*  Boehring-er's   is   good. 
t  Not  oflficial. 
{  Proprietary. 


185 

WEIGHTS  AND  MEASURES. 

METRIC  SYSTEM. 

1  kilogram   (kg.)^^l  litre  of  distilled  water  at  maximum 
density,  i.e.,  at  4°  C.  and  760  mm.  pressure. 

1  kg.         =1000  grams. 

1.0  gm.    =gram  gm.). 

0.1  gm.     =  decigram   (dg.). 

0.01   gm.  =  centigram   (eg.). 

0.001  gm.=:  milligram   (mg.). 

APOTHECARIES'  OR  TROY  WEIGHT. 

1  grain  or  gr.  =  0.065  gm. 

1  drachm  (dr.  or  drach.)  or  3  =  60  grs.  or  approx.  4  gm. 
1  ounce  (oz.)  or  5=18  dr.  =  480  grs.  or  approx.  30  gm. 
1  pound  (lb.)  =:12  ^  or  approx.  375  gm. 

U.  S.  APOTHECARIES'  OR  WINE  MEASURE. 

1  minim  (min.)   or  m.  =  0.062  c.c.   (or  approx.  1  drop  of 
water). 

1  fl.  drachm  (drach.  or  dr.)  or  5  =  60  m.  or  approx.  4  c.c. 
1  fl.  ounce*  (oz.)  or  5  =  8  dr.  ^  480  m.  or  approx.  30  c.c. 
1  pint  (O)  =:  16  3  or  approx.  480  c.c. 


1  fl.  oz.  of  water  weighs  455.6  grs. 


